Peter McEachran House Care Home Service 12 Kennyhill Square Dennistoun Glasgow G31 3LW Inspected by: (Care Commission Officer) Type of inspection: Daphne Ndlovu Announced Inspection completed on: 3 October 28 1/17
Service Number Service name CS23138 Peter McEachran House Service address 12 Kennyhill Square Dennistoun Glasgow G31 3LW Provider Number dummy Provider Name SP23339 Glasgow City Council Inspected By dummy Inspection Type Daphne Ndlovu Care Commission Officer Announced dummy Inspection Completed Period since last inspection 3 October 28 7 Months dummy Local Office Address Central West Region 4th Floor 1 Smithhills Street Paisley PA1 1EB Tel: 141 843 423 Fax: 141 843 4289 dummy 2/17
Introduction Peter McEachran House is a purpose built care home for older people. The home is owned and managed by the Glasgow City Council. The service registered with the Care Commission in April 22. The home is divided into four units each with its own kitchen, sitting and dining room. Bedrooms are single accommodation with en-suite toilet and hand wash facilities. There are no en-suite bath or shower facilities although there are adequate numbers of communal baths and showers to meet the needs of the current user group. The home has recently had the gardens landscaped to include raised planters and defined walkways. The home is situated in the East End of Glasgow, close to local shopping and other amenities. There is good access to public transport and there is a small private car park. There is a local park adjacent to the home with private access for service users. The aim of the home is to provide care and support to older people who can no longer live in their own home and to encourage them to continue using local facilities and keep up friendships out with the home. Based on the findings of this inspection the service has been awarded the following grades: Quality of Care and Support - 4 - Good Quality of Environment - 4 - Good Quality of Staffing - 4 - Good Quality of Management and Leadership - 4 - Good This inspection report and grades represent the Care Commission s assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. Please refer to the care services register on the Care Commission s website (www.carecommission.com) for the most up-to-date grades for this service. Basis of Report Before the Inspection The announced inspection took place on 2nd October 28 between 9:3hrs and 18:3hrs and continued on 3rd October 28 between 1:15hrs and 13: hrs. The Annual Return The service submitted a completed Annual Return as requested by the Care Commission. The Self-Assessment Form The service submitted a self-assessment form as requested by the Care Commission Views of service users 14 Questionnaires were returned to the Care Commission, in addition to that the officers spoke with 1 service users over the course of the inspection Regulation Support Assessment 3/17
The inspection plan for this service was decided after a Regulation Support Assessment (RSA) was carried out to determine the intensity of inspection necessary. The RSA is an assessment undertaken by the Care Commission Officer (CCO) which considers complaints activity, changes in the provision of the service, nature of notifications made to the Care Commission by the service (such as absence of a manager) and action taken upon requirements. The CCO will also have considered how the service responded to situations and issues as part of the RSA. LOW This assessment resulted in this service receiving a low RSA score and so a low intensity inspection was required. The inspection was based on the relevant Inspection Focus Areas and associated National Care Standards, recommendations and requirements from previous inspections and complaints or other regulatory activity. This service will receive a number of inspections over the year 8/9. This inspection was based upon requirements and recommendations made at the last inspection on 28/2/28. During the inspection process Staff at inspection The inspection was conducted by one Officer from the Care Commission Daphne Ndlovu. Discussions were conducted with the manager, the depute, 1 senior care officer and 1 care officer. Evidence During inspection, evidence was gathered from a number of sources including: discussion with service users and carers, a review of a range of policies, procedures, records and other documentation, including the following; supporting evidence from the up to date self assessment Service user s personal plans Records of supervision Infection control policy Whistle Blowing policy Staff training records Records of accidents and Incidents Complaints Procedure Staff meeting minutes Service user s meeting minutes Annual report Inspection Focus Areas and links to Quality Themes and Statements for 28/9 The inspection was based on the Quality Assessment Framework. This report reflects four Quality Themes appropriate to a Care Home for Older People Service: - Quality of Care and Support - Quality of the Environment - Quality of Staffing - Quality of Management and Leadership Inspection Focus Area: Notifications Details of the inspection focus and associated Quality Themes to be used in inspecting each 4/17
type of care service in 28/9 and supporting inspection guidance, can be found at: http://www.carecommission.com/ Fire Safety Issues The Fire (Scotland) Act 25 introduced new regulatory arrangements in respect of fire safety, on 1 October 26. In terms of those arrangements, responsibility for enforcing the statutory provisions in relation to fire safety now lies with the Fire and Rescue service for the area in which a care service is located. Accordingly, the Care Commission will no longer report on matters of fire safety as part of its regulatory function, but, where significant fire safety issues become apparent, will alert the relevant Fire and Rescue service to their existence in order that it may act as it considers appropriate. Further advice on your responsibilities is available at www.infoscotland.com/firelaw Action taken on requirements since last Inspection There were no requirements or recommendations arising from the last inspection. Comments on Self Assessment A fully completed self assessment document was submitted by the service. It was completed to a satisfactory standard and gave relevant information for each of the Quality Themes and Quality Statements. The service identified its strengths and some areas for future development and gave evidence of service user involvement and how they planned to implement change. This information was sampled and used during the inspection process. View of Service Users Staff are helpful, first class Anything they say they ll do, they do. We are well looked after, staff are very nice. When they were decorating my room, they asked me what colours I liked. There are no restrictions in me putting up family photographs on the wall. I like it here, the food is always good There is nothing that annoys me or I would remember. My key worker is a good person. It s a good place, I wouldn t have stayed here for a year if it wasn t. View of Carers They have done everything in here to make my mum s quality of life better. I can speak to the manager or depute anytime they are always very helpful The care is very good in here but staff could spend more time with the residents. I have all the faith in the management of this place. They go out that extra mile Care doesn t come from an SVQ, it comes from the heart. This place is the best in Glasgow. They have got a special way of working with my mother If care commission wanted a flagship to run off, this is the place. 5/17
Quality Theme 1: Quality of Care and Support Overall CCO Theme Grading: 4 - Good Statement 1: We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service Strengths The organisation had a draft participation strategy that detailed how they intended involving service users and their carers, the different levels that they could be involved in and the expected outcomes for people who use the service. Service user and carers meetings took place. Service users and carers spoken with confirmed this and minutes of meetings were also sampled. Some quality assurance systems which involved service users and carers were in place. The service had developed service user and carer questionnaires and these demonstrated high levels of satisfaction with the quality of care. Results of the questionnaires were published in the service's newsletter. Within the personal plans sampled, reviews involving the service user, their carers, and different people appropriate to that individual's care, took place at six monthly intervals. From the minutes of the review meetings that were sampled, it was clear that service users and their carers had an input in the individual's plan of care and support. One carer shared that he had requested a hot air drier to be installed in his wife's bathroom so that she could dry her hand properly as she had lost use of one hand and found it difficult to get hands dried with a towel. This was now being implemented and both the carer and the service user had been kept in the loop with emails going to and from the service manager and the maintenance department. Service users spoken with confirmed that they were fully involved in the reviews. One of the carers spoken with commented; 'my relative is receiving wonderful care, it is first class. Staff are always very caring, helpful and friendly.' And another, 'Care doesn't come from an SVQ but from the heart. You've either got it or you don't and the staff here have definitely got it.' Areas for Development The organisation has yet to finalise their participation strategy which currently remains in draft form. From the questionnaires returned to Care Commission it was noted that when asked if they knew who their key worker was or if the y were aware of the complaints procedure, some people had indicated that they didn't know who the key worker was and that they did not know about the complaints procedure. The manager has taken this into consideration and plans to introduce as standing agenda, key worker information and complaints procedure. Although questionnaires surveys had been carried out and in some areas, action taken to address issues, no analysis of the findings had been put together or shared with those surveyed. The Manager was aware that existing systems of quality assurance which include service user and carer participation in evaluating the service need to be developed further. 6/17
CCO Grading 4 - Good Number of Requirements Number of Recommendations Statement 4: We use a range of communication methods to ensure we meet the needs of service users. Service Strengths Residents and their relatives commented positively about the approach of all staff stating that they felt staff knew them well and could respond quickly and appropriately to their needs and requests. Within the service there was a creative writing project, which involved service users who had been diagnosed with dementia. Through the work of the project, service users have been able to express themselves through poetry. Individuals had personal plans which included life histories, likes and dislikes. In most cases, where the individual had communication needs, these were identified and a care plan on how to meet these needs was put in place. Some staff had undertaken total communication training. Birthdays, annual festivals and celebrations were marked as special events. Religious beliefs were respected and encouraged. The keyworker system that operated within the service helped to improve and maintain communication. The service had recently re introduced a newsletter. Information advising people on the service's complaints procedure, the care commission's complaints procedure and independent advocacy, was displayed on the notice board. Areas for Development It was noted that in some care plans, service agreements and risk assessments sampled, there was either no space for the service user or their carer to sign to indicate their involvement. In some cases where there was space for the service user signature, their signature was missing. The manager has agreed to ensure that this is implemented. CCO Grading 5 - Very Good 7/17
Number of Requirements Number of Recommendations 8/17
Quality Theme 2: Quality of Environment Overall CCO Theme Grading: 4 - Good Statement 1: We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service Strengths See Section 1.1 for further evidence to support this statement. Service users and their families confirmed they were consulted in redesigning the garden. One service user informed the officer that they wanted to grow tomatoes and strawberries and that this had been taken into consideration Bedrooms were personalised. Service users were encouraged to bring their own furniture and rooms were individualised. Personal plans included individual risk assessments. General risk assessments were completed regarding the environment. Families and service users were involved in decorating bedrooms. Service user's views on the activities they liked were sought through questionnaires. Areas for Development The Manager was aware that existing systems to involve service users and carers in decisions about improving the environment need to be further developed. CCO Grading 4 - Good Number of Requirements Number of Recommendations Statement 3: The environment allows service users to have as positive a quality of life as possible. Service Strengths On the day of the inspection the home was clean and the temperature within was pleasant. Service users appeared to be comfortable and relaxed. The atmosphere was a friendly, warm and welcoming one. Service users and their visitors had a choice of areas to sit in. An infection control policy was in place. 9/17
The building was barrier free, with a lift access to the upper floor. Some of the comments made by service users and carers included; 'It's just like a hotel' If care Commission wanted a flagship to run off, this is the place.' It's the best place in Glasgow.' Bedrooms were personalised with a range of personal equipment and family photographs. The inspection report from the last inspection was displayed on the notice board, together with other useful information such as health advice, advocacy and local community events. The service had good links with a local school. Young people from the school sometimes provided entertainment for the residents on special occasions like Christmas. On the day of the inspection, one of the young people from the school was in doing their work experience. They were observed to be interacting very well with the residents. Areas for Development Although risk assessments had been carried out and both staff and service users said the risk assessments were drawn up with all parties involved, service user's signatures on the risk assessments were missing. The manager has agreed to ensure that this is implemented. CCO Grading 5 - Very Good Number of Requirements Number of Recommendations 1/17
Quality Theme 3: Quality of Staffing Overall CCO Theme Grading: 4 - Good Statement 1: We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths See Section 1.1 for further evidence to support this statement. Staff spoken with as part of this inspection demonstrated an understanding of their roles and felt well supported. Questionnaires sought residents' views about staff and the care that was provided. Their responses demonstrated that they felt that staff were good or very good and that staff provided good well cared for. The deputy manager carried out periodic assessments on temporary staff. The assessments included consultation with service users to find out how effective that person was as a worker. There was evidence demonstrating that as a result of the service user input, some temporary workers had had to undergo some training or in some cases had their temporary contracts terminated A key worker system was in operation within the service. A recruitment policy was in place. Staff were recruited following good practice of taking up references and disclosures. Carers and service users spoken with expressed satisfaction and confidence in the staff. Areas for Development The Manager was considering ways in which the existing systems of quality assurance could be enhanced to further evidence service user and carer participation in the quality of staffing. Service users and carers were currently not involved in the recruitment of staff or in staff development. It was noted that the recruitment policy did not mention service user or carer involvement. The manager shared that the organisation is currently discussing and considering how to involve service users in recruitment. CCO Grading 4 - Good Number of Requirements Number of Recommendations 11/17
Statement 3: We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service Strengths Family members spoken with were very complimentary about the service and the care. One of the service user commented, 'They go out that extra mile, staff here are really really good.' The service had policies in relation to recruitment, training and development and whistle blowing. The organisation had a process to ensure that staff were recruited in line with best practice guidance. The staff induction pack included information on key working, fire procedures security, job description and the service user's charter of rights. Staff received supervision. Staff had visited the Stirling Dementia Centre in the past. Staff spoken with spoke of a supportive management. The Officer spent time speaking with staff and observing their practice. Staff were found to be committed, experienced, warm and respectful in their approach to residents. The care and support offered to residents was provided in a dignified way with staff taking time to be patient and listen to their requests. Areas for Development The organisation is in the process of introducing Professional Development Plans for each member of staff. The manager hopes to implement these once she has attended the relevant training. This will be followed up at the next inspection Staff had not undertaken training in Protection Of Vulnerable Adults. Staff would also benefit from restraint training. (recommendation 1) From sampling of medication it was noted that some of the eye drops did not have a 'date of opening' marked on them. The codes to indicate reason why medication had been omitted were not always marked in the relevant space on MAR sheets. CCO Grading 4 - Good Number of Requirements Number of Recommendations 12/17
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Quality Theme 4: Quality of Management and Leadership Overall CCO Theme Grading: 4 - Good Statement 1: We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service Strengths See Section 1.1 for further evidence to support this statement The organisation had a development plan for 27-21. Correspondence had been made to service users about proposals for future development plans of Local authority Homes. The organisation carried out annual surveys of views of service users. Results were published and made known to service users. Through discussions with the manager, it was evident that she was aware of issues that were notifiable to both SSSC and Care Commission. Areas for Development More work needs to be done to ensure service users and carers are involved in assessing and improving the quality of management and leadership of the service. CCO Grading 4 - Good Number of Requirements Number of Recommendations Statement 4: We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide. Service Strengths Six monthly review meetings involving service users, their carers, staff and other personnel involved in the person's care, took place. From the minutes of the review meetings, it was evident that service users and their carers put forward their views. One of the service users spoken with was part of the planning group for the new build service. A robust complaints procedure was in place. Information advising on the Care Commission's complaints procedure was displayed on the notice board. The organisation published an annual Report. A statement of aims and objectives was in place. 14/17
Various quality assurance audits were carried out in the service for example, health and safety audits, pharmacist carried out 3 monthly audits on medication and the manager and depute carried out audits on personal plans and other systems in the service. The organisation used Audit Scotland to compare it's performance against other councils. A complaints procedure was in place. Service users and carers spoken with were also aware of the care commission's complaints procedure. Staff spoke of being supported by management even for personal matters. The presence of both the manager and depute was visible in the service. Areas for Development The manager should continue to develop systems to increase service user and carer involvement within this theme. CCO Grading 4 - Good Number of Requirements Number of Recommendations 15/17
Regulations / Principles National Care Standards 16/17
Enforcement There has been no enforcement action against this service since the last inspection. Other Information None. Requirements None. Recommendations 1. Staff should receive relevant training such as Protection of Vulnerable Adults and Restraint, to help them put the services policies and procedures into practice. National Care Standards for care Homes for Older People. Standard 5.6 Management and Staffing Arrangements. Daphne Ndlovu Care Commission Officer 17/17