Levenhall Nursing Home Care Home Service Adults 14 Hope Place Musselburgh EH21 7QD Telephone:

Levenhall Nursing Home Care Home Service Adults 14 Hope Place Musselburgh EH21 7QD Telephone: 0131 665 4478 Inspected by: Katie Wood Type of inspection: Unannounced Inspection completed on: 23 January 2012

Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 6 3 The inspection 14 4 Other information 36 5 Summary of grades 37 6 Inspection and grading history 37 Service provided by: Renaissance Care (Scotland) Limited Service provider number: SP2004006990 Care service number: CS2004080471 Contact details for the inspector who inspected this service: Katie Wood Telephone 0131 653 4100 Email enquiries@scswis.com Levenhall Nursing Home, page 2 of 39

Summary This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change after this inspection following other regulatory activity. For example, if we have to take enforcement action to make the service improve, or if we investigate and agree with a complaint someone makes about the service. We gave the service these grades Quality of Care and Support 3 Adequate Quality of Environment 3 Adequate Quality of Staffing Quality of Management and Leadership N/A N/A What the service does well Staff in the service are caring towards the residents. They know the residents well, and have good relationships with resident's' friends and families. The Provider listens to what we say at our inspections, and works to try to make the improvements we identify. Senior management staff are often available in and around the Home. What the service could do better The service needs to improve the quality of the environment in the Home, and to get better at the way they plan care. The staff need to have more time to spend talking and socialising with the residents, and to enable them to provide activities, even in the times when the activities staff are not available. When the service has listened and responded to suggestions made by residents or their relatives, they need to be better at reporting back on any progress they have made. Levenhall Nursing Home, page 3 of 39

What the service has done since the last inspection The service has continued to make opportunities for residents and their visitors to have their say about the service. However, they have not made as much progress as we had hoped with the requirements made by the Care Commission at their last inspection. Conclusion Levenhall Nursing Home is a small care home within a close local community, with a caring group of staff. Many of the residents relatives visit regularly, and are involved in some of the decisions made about the service. Who did this inspection Katie Wood Levenhall Nursing Home, page 4 of 39

1 About the service we inspected Levenhall Nursing Home is a care home facility registered to provide 24 hour care for up to 26 older people. the Home is situated in a residential area on the eastern outskirts of Musselburgh, approximately one mile from the town centre and close to a number of main bus routes. The facility is comprised of two semidetached houses which have been converted to one building, with accommodation on two floors. Stairs and a passenger lift give access to the upper floor. A conservatory at the rear of the building serves as a dining room for some residents, and overlooks a large garden. There are two public sitting rooms on the ground floor and one on the first floor, and the service has its own kitchen and small laundry facilities. Before the 1 April 2011 this service was registered with the Care Commission. On this date, the new scrutiny body, Social Care and Social Work Improvement Scotland ("the Care Inspectorate"), took over the work of the Care Commission, including the registration of care services. This means that from 1 April 2011this service continued its registration under the new body, the Care Inspectorate. The Home's philosophy of care states that its primary aim is to ensure that residents "enjoy a good quality of life within a pleasing and safe environment" and that this will be achieved "by ensuring that the quality of staff is of a high standard, and that they receive appropriate support, leadership and training to carry out their duties to the best of their abilities and in line with legal requirements and best practice guidance". Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 3 - Adequate Quality of Environment - Grade 3 - Adequate Quality of Staffing - N/A Quality of Management and Leadership - N/A This report and grades represent our 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. You can find the most up-to-date grades for this service by visiting our website www.scswis.com or by calling us on 0845 600 9527 or visiting one of our offices. Levenhall Nursing Home, page 5 of 39

2 How we inspected this service The level of inspection we carried out In this service we carried out a medium intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection We wrote this report following an unannounced inspection, carried out by Katie Wood, Inspector with the Care Inspectorate, between 9:15 am and 7:15 pm on the 9 January 2012. We met with the Manager of the service, Depute Manager, the Operations Director and the Managing Director from Renaissance Care Ltd to give feedback on the outcome of the inspection on the 23 January 2012. During our inspection, we gathered evidence from a variety of sources including: information from the service's Annual Return to the Care Inspectorate; information from the service's self assessment form; the service's participation strategy; minutes of meetings; residents' personal plans; some of the policies and procedural guidance used in the service; maintenance and servicing records for equipment used in the service; results from audits and surveys; accident and incident records; complaint records; visual examination of the premises; observation of practice. We spoke with the Manager, Depute Manager, two care staff, an activities coordinator, and the cook. We engaged in conversation with a number of residents during our visit, but because of their frailty or level of cognitive impairment, we were not able to ask direct questions about their experiences of care in the service. Instead, we observed the staff working on the upper floor for approximately an hour and a half during the morning and over lunchtime, to see how they interacted with residents, and to observe the care that resident received. We also sent the service questionnaires and asked that they pass these on to residents or visitors who might want to contribute to the inspection. We asked the service to support those residents who might want to complete a questionnaire but needed assistance to do so, either by asking staff to assist, or by using an independent advocate to help. We received 10 completed questionnaires from relatives or other visitors, but no completed Levenhall Nursing Home, page 6 of 39

questionnaires from residents. We have reflected the views or residents and visitors in the appropriate areas of this report. Grading the service against quality themes and statements We inspect and grade elements of care that we call 'quality themes'. For example, one of the quality themes we might look at is 'Quality of care and support'. Under each quality theme are 'quality statements' which describe what a service should be doing well for that theme. We grade how the service performs against the quality themes and statements. Details of what we found are in Section 3: The inspection Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at www.firelawscotland.org Levenhall Nursing Home, page 7 of 39

What the service has done to meet any requirements we made at our last inspection The requirement The Provider must ensure that care plans clearly reflect the wishes, choices and preferences of the individual service user. This is in order to comply with SSI 2002/114 Reg 4(1)(a) - a regulation regarding the health and welfare of service users, and Reg 5(1) and 5(2)(c) - a regulation regarding personal plans. It is also in accordance with the National Care Standards Care Homes for Older People Standard 6 - Support Arrangements, the SSSC Code or Practice for Social Service Workers Sections 1.1, 1.2, 1.3 and 3.1, and the Nursing and Midwifery Council (NMC) Guidance for the Care of Older People March 2009. Timescale for implementation: Within 6 weeks of publication of this report. What the service did to meet the requirement We have discussed the way the service plans care in Statements 1 and 3 of Quality of Care and Support. We have made a different requirement about care planning. The requirement is: Not Met The requirement The Provider must ensure that staff are employed in sufficient numbers to meet all of the needs of service users. This is in order to comply with SSI 2002/114 Reg 13(a) - a regulation regarding staffing. It is also in accordance with the National Care Standards Care Homes for Older People Standard 5.7 - Management and Staffing Arrangements, and Standard 8 - Making Choices, Standard 12 - Lifestyle. Timescale for implementation: Within4 weeks of publication of this report. What the service did to meet the requirement Although we could see that the service had taken steps to try and address this requirement, by employing staff specifically to plan and provide activities for residents, there was still evidence at inspection that staffing numbers and availability Levenhall Nursing Home, page 8 of 39

was having an impact on the quality of care staff were able to provide for residents. We have made a different requirement about staffing in Statement 3 of Quality of Care and Support. The requirement is: Not Met The requirement The Provider must measure the lounges and conservatory and submit those measurements to the Care Commission for consideration. This is in order to comply with SSI 2002/114 Reg 10(1)- a regulation regarding fitness of premises. It is also in accordance with the National Care Standards Care Homes for Older People Standard 4 - Your Physical Environment. Timescale for implementation: Within 3 weeks of publication of this report. What the service did to meet the requirement The service gave this information to the Care Commission following their last inspection of the service. We have commented further on the space available to residents in Statement 3 of Quality of the Environment, and we continue to work with the service to look at ways to improve this. The requirement is: Met The requirement The Provider must make proper provision for the health and welfare of service users, and ensure that care is planned in a way which clearly demonstrates how all of the service user's health and welfare needs are to be met. In order to do so, the Provider must: ensure that all staff are aware of and fully implement policies in use in the service which relate to the provision of care, including policies on care planning, nutrition, management of challenging behaviour, and risk assessment; ensure that care plans accurately identify all of the service users' needs, and clearly demonstrate how all of those needs are to be met, taking into consideration best practice guidance, specifically in relation to nutrition,challenging behaviour; ensure that care is planned in a manner which reflects the principles of the Regulation of Care (Scotland) Act 2001 and the Adults With Incapacity (Scotland) Act 2000; ensure that risk assessment tools are used effectively and inform the way care is planned; Levenhall Nursing Home, page 9 of 39

ensure that staff evaluate the effectiveness of planned care, and that those evaluations are accurately documented. This is in order to comply with SSI 2002/114 Reg 2 - a regulation regarding principles of the Act, Regs 4(1)(a) and (c) - regulations regarding welfare of service users and Reg 5 - a regulation regarding personal plans. It is also in accordance with the National Care Standards Care Homes for Older People Standard 6 - Support Arrangements, the SSSC Code of Practice for Employers Sections 1.4, 1.5 and 2.2, the SSSC Code of Practice for Social Service Workers Sections 1.1, 3.1, 4.2, 4.3, 4.4, 6.1, and 6.2, and the Nursing and Midwifery Council (NMC) Guidance for the Care of Older People March 2009, NMC Standards of Conduct, Performance and Ethics for Nurses and Midwives April 2008. Timescale for implementation: Within 6 weeks of publication of this report. What the service did to meet the requirement As noted above, we have commented on care planing in Statements 1 and 3 of Quality of Care and Support, and we have made a different requirement about care planning in Statement 3 of Quality of Care and Support. The requirement is: Not Met Levenhall Nursing Home, page 10 of 39

The requirement The provider must ensure that people who use care services are consulted and offered a range of appropriate, purposeful, recreational and stimulating activities on a regular basis. In order to achieve this, the Provider must ensure that social and leisure care is planned in a way which takes into account the wishes, preferences, choices and aspirations of individual service users, including the information which is gathered as part of the life history work. This is in order to to comply with SSI/114 Reg 4 (1)(a) - a regulation regarding the health and welfare of service users. It is also in accordance with the National Care Standards Care Homes for Older People Standards 5.4 and 5.7 - Management and Staffing Arrangements, the SSSC Code of Practice for Employers Section 1.5, the SSSC Code of Practice for Social Service Workers Sections 1.1 and 1.3, and the NMC Guidance for the Care of Older People March 2009. Timescale for implementation: Within 4 weeks of publication of this report. What the service did to meet the requirement We found that the Provider had taken steps to improve the range of activities available by employing staff for 26 hours a week, whose role was to plan and provide activities. However, as we have described in Statements 1 and 3 of Quality of Care and Support, it was not yet evident that the range of planned activities was available to all residents in the Home who might wish to take part, or that the programme of activity fully reflected the interests or abilities of all of the residents. This was at times limited by staff availability. We have made requirements about staffing and about choice and dignity in Statements 1 and 3 of Quality of Care and Support. The requirement is: Not Met The requirement The Provider must make proper provision for the health and welfare of service users. In order to do so, the Provider must ensure that medication management in the Home is carried out in line with current legal requirements and best practice guidance. This is in order to comply with SSI 2002/114 Reg 4(1)(a) - a regulation regarding the health and welfare of service users. It is also in accordance with the the National Care Standards Care Homes for Older People Standard 15 - Keeping Well Medication, the SSSC Code of Practice for Employers Sections 1.4, 1.5 and 2.2, the SSSC Code of Practice for Social Service Levenhall Nursing Home, page 11 of 39

Workers Section 6.1, the Royal Pharmaceutical Society of Great Britain The Handling Of Medicines in Social Care 2007, and the NMC Standards for Medicines Management 2007. Timescale for implementation: Within 4 weeks of publication of this report. What the service did to meet the requirement We found that this requirement had been met. The requirement is: Met What the service has done to meet any recommendations we made at our last inspection At the last inspection carried out by the Care Commission, a number of recommendations were made regarding: the way the service gathers the views of people using the service, and takes these into account; the way the service involves people in their quality assurance systems; provides training for staff on meaningful activity. We have commented on these aspects of the service in Statements 1 and 3 of quality of Care and Support. The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. Before we carried out this inspection, the Provider was asked to complete a self assessment, identifying what they thought the service did well, and areas where they planned to improve. We received the self assessment form, and it gave us some information about the service. However, it lacked detail, and the entries were not always relevant to the particular Statement. The service awarded itself grades of Levenhall Nursing Home, page 12 of 39

"Very Good" for all Statements, but we did not find that realistic as it was not supported by the evidence we found when we inspected. Taking the views of people using the care service into account Prior to the inspection visit, we sent the service questionnaires and asked that they distribute them to residents who wanted to contribute to the inspection. We asked the service to support those residents who might want to complete a questionnaire but needed assistance to do so, either by asking staff to assist, or by using an independent advocate to help. However, we did not receive any completed questionnaires from residents. During our visit, we engaged a number of residents in conversation. Some of these appeared relaxed and at ease, though a few were restless or less at ease. Because of their level of frailty, most of the people we spoke with were not able to answer direct questions about their care, so we spent time during the day observing practice in the lounge upstairs, to see how staff interacted with residents. We have described what we observed throughout this report.. Taking carers' views into account We received 10 completed questionnaires from relatives or other visitors to the service. Of these, five people "strongly agreed" and 5 "agreed" with the statement that overall, they were happy with the quality of care their relative or friend received. Two people indicated that they were not sure there were enough skilled staff to meet people's needs, two were not satisfied that their friend or relative's personal belongings were taken care of, and two did not think there were enough social events or activities. Comments made included: "There do not appear to be sufficient funds for events and activities"; "There are too many "breaded" options (on the menu eg fishcakes or breaded chicken) - obviously the menus are designed to fit a budget/cost per resident, which limits choice"; ""I feel (my relative) is given excellent care. The staff are very attentive and act in an appropriate manner. We are informed of any problems (my relative) is experiencing and consulted about her care". Levenhall Nursing Home, page 13 of 39

3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 3 - Adequate 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 Provider had a Participation Strategy, which set out how the service planned to gather the views of residents and their relatives or representatives. This included: residents and relatives meetings; involvement in reviews of care; one-to-one discussions with the Manager; opportunities for residents and relatives to meet with the Directors from Renaissance Care Ltd; the use of surveys and questionnaires; a residents' committee. The strategy set out a range of topics on which the service planned to consult with residents and their relatives, including: planning redecoration; day to day running of the service; the management of the service; how to improve the service; outings and events; self assessment of the service before the inspection. The strategy stated that "meetings will all be minuted with action plans put in place which are mutually agreed and issues moved forward". It also noted that resources would be made available to help and support residents who find communication more difficult, including the availability of an advocacy service and the use of communication tools. Levenhall Nursing Home, page 14 of 39

We saw minutes of residents meetings held in December, October and July 2011. We could see that topics such as plans for Christmas celebrations, activities offered in the Home, and the menus were discussed. We also saw minutes of relatives' meetings held in October and July 2011. At these meetings we could see that information was shared with relatives about the company structure of Renaissance Care Ltd, the process of the Care Inspectorate Inspection, activities, and the use of advocacy services. We could see from records that resident and relatives had been involved in the self assessment of the service. The self assessment had been discussed at a relatives' meeting, and peoples views had then been sought through the use of a questionnaire. We also saw that the results from a resident survey had been pinned up on a notice board in the Home. This shared information with the residents and visitors to the Home. It would have been helpful to have information about what questions were asked in the survey made available as well as the results, to help people to understand what the results meant. When we spoke with staff, they were aware of the principle of the participation strategy in recognising the rights of residents and their representatives to make choices and to influence the way the service is provided. One of the Directors told us that they visited the service regularly, and attended some of the meetings. This meant that they heard the views or suggestions put forward by resident or relatives, and were available to speak with people on a one-to-one basis. We saw from care records that one resident had recently received support from an independent advocate. Areas for improvement When we spoke with the Manager about the service's participation strategy, she referred us to a visual diagram which set out the relationships people who used the service had with agencies involved in providing care and support, and the principles which underpin the Scottish Government's National Care Standards. No reference was made to the service's written participation strategy, and it was not clear what the visual representation meant on a day to day basis for residents, or the staff providing care. (See requirement 1 below) We could see from the minutes of meetings that suggestions or comments were made, but it was not evident from the records we were shown that these were followed up and led to positive outcomes for residents. There was not always an action plan drawn up following the meetings, and responsibilities for carrying forward Levenhall Nursing Home, page 15 of 39

any actions were not identified. Actions identified at one meeting were not reviewed or progress reported on at subsequent meetings. One relative commented on this in the questionnaire they completed. (See requirement 1 below) Personal plans we saw were not holistic or person centred. They often used general statements that did not identify the specific needs or wishes of the individual resident. The aims set out in each plan did not reflect the perspective of the resident. (See requirement 2 in Statement 3 of Quality of Care and Support) While we could see that relatives were invited to take part in reviews of care, we did not see evidence that residents were involved. Where residents chose not to, or were unable to, take part in care reviews, there was no evidence that the service had taken steps to try to seek their views and represent them at the review meeting. For example, before a review of care some services will ask the keyworker for the resident to gather observations for a period of time about how a resident is feeling or responding to different aspects of care. The keyworker will then act as the voice of resident by sharing those observations as part of the review of care. (See requirement 2 in Statement 3 of Quality of Care and Support, and recommendation 1 below)) Although there was a keyworker system in the Home, this was not operated in a way that supported the development of relationships with residents and relatives. We have described this in more detail in Statement 5 of Quality of Care and Support. (See recommendation 1 below) When we observed practice on the upper floor of the Home during the day, we saw little evidence of residents making choices or influencing the way their care and support were provided. Music was being played loudly in the lounge, making it difficult for people to hold conversations. The same music played throughout the morning. Staff were very busy attending to tasks of care, with little time to spend in meaningful interaction with the residents. We saw that there was a programme of activity on display, but this was not being delivered for the residents in the upstairs lounge. We saw an "allocations" book which set out which area of the Home each member of staff was to work in each day, and this showed that staff were allocated either to work downstairs or upstairs, and swapped over at the middle of their shift. This did not help staff to work to support residents in an individual way, or to build relationships, particularly with those residents with dementia. One relative who completed our questionnaire commented that "The named carer does not appear to be the co-ordinator of aspects of (my relative's) care". The allocations book also noted the allocation of bath times for residents. From this it appeared that all apart from one resident were allocated one bath a week, which did not evidence individual choice or preference. (See requirement 2 below) Levenhall Nursing Home, page 16 of 39

Grade awarded for this statement: 3 - Adequate Number of requirements: 2 Number of recommendations: 1 Requirements 1. The Provider must provide the service in a manner which affords service users choice in the way the service is provided to them. In order to do so, the Provider must: ensure that residents, relatives or representatives and staff are familiar with the service's own written Participation Strategy; ensure that the service's own Participation Strategy is fully implemented in the service; provide training for all staff on the Participation Strategy, and how this affects the way they provide care on a day to day basis; ensure that when the views of residents and relatives or representatives are sought, these are used in a way which results in positive outcomes for residents; ensure that the outcomes from resident and relative involvement are clearly recorded and shared with all interested parties. This is in order to comply with SSI 2011/210 Reg 3 - a regulation regarding Principles. It is also in accordance with the National Care Standards Care Homes for Older People Standard 8 - Making Choices, Standard 11 - Expressing Your Views, Standard 17 - Daily Life, the Nursing and Midwifery Council (NMC) Guidance for the Care of Older People, The Scottish Government Standards of Care for Dementia in Scotland, the SSSC Code of Practice for Employers Sections 1.4, 1.5 and 2.2, and the SSSC Code of Practice for Social Service Workers Sections 1.1,.1.2, 1.3 and 3.1. Timescale for implementation: Within 13 weeks of publication of this report. 2. The Provider must provide the service in a manner which respects the dignity of residents and affords them choice in the way their care is provided. In order to do so, the Provider must ensure that care is planned and delivered in a way which reflects the individual wishes and preferences of each service user, specifically but not exclusively in relation to bathing. This is in order to comply with SSI 2011/210 Reg 3 - a regulation regarding principles, and Reg 4(1)(b) - a regulation regarding the welfare of users. Levenhall Nursing Home, page 17 of 39

It is also in accordance with the National Care Standards Care Homes for Older People Standard 6 - Support Arrangements, Standard 8 - Making Choices, the NMC Guidance for the Care of Older People 2009, and the SSSC Code of Practice for Social Service Workers Sections 1.1, 1.3 and 3.1. Timescale for implementation: Within 24 hours of receipt of the draft copy of this report. Recommendations 1. The Provider should review the keyworking arrangements in the Home, to ensure that they are operating in a way which is in line with the Provider's own definition of keyworking, and are effective in supporting relationships between residents and relatives, and staff. This is in accordance with the National Care Standards Care Homes for Older People Standard 5.4 - Management and Staffing Arrangements, Standard 7.1 and 7.2 - Moving In, and the SSSC Code of Practice for Employers Section 1.4. Statement 3 We ensure that service user's health and wellbeing needs are met. Service strengths We looked at some service users' personal plans. We saw that in some of them there was useful information about the resident's care needs. We also saw that staff were encouraged to use a range of assessment tools to help them to identify residents' needs. We found that the Provider had a range of policies and procedures to guide staff in the way they provided care and support for residents. These included: nutrition; pain management; safe moving and handling; medication. There was also a policy which gave staff guidance on the circumstances in which residents might choose not to be resuscitated in the event of a serious or sudden deterioration in their health. We saw that staff had worked with some residents' GPs to ensure their wishes in such circumstances had been discussed and recorded. When we observed staff working in the service, we saw that they were busy attending to residents' physical care needs. We saw that staff attended to residents as quickly as possible when they needed assistance, and were pleasant and polite in the way Levenhall Nursing Home, page 18 of 39

they spoke with residents. We saw that when staff had time, they engaged residents in conversation. From care records we could see that staff in the service helped residents to access healthcare services, and sought advice from healthcare professionals. There was evidence in care records that podiatry and optician services were made available to residents, and we could see that community healthcare staff visited residents, for example a psychiatric nurse and dietician. There was a requirement made at the last inspection carried out by the Care Commission about how the service managed residents medication. When we looked at medication administration records (MARs) at this visit, we could see that this had improved. We spoke with a cook about how information about residents' dietary needs was shared. She said that care staff passed on information about special diets to the staff in the kitchen. The service employed activities staff for a total of 26 hours a week. There were programmes of activities on display throughout the Home. Activities designed to give both mental and physical stimulation were provided, for example through word games and reminiscence work, as well as gentle exercise such as ball games. We saw photographs of events that had taken place in the Home to celebrate special festivals or residents' birthdays. Areas for improvement Although we could see that staff worked hard to attend to residents who needed assistance, we also saw that at times during the day they had little opportunity to stop and chat because they were busy with physical tasks of care. (See requirement 1 below) We found that the service needed to improve the way that they planned care and support for residents. Care plans needed to be more person centred, and the aims identified in care plans should reflect the goals of the individual resident. Staff often used general statements in care plans, which were not specific to the needs or wishes of the individual resident. (See requirement 2 below) Although there were a range of assessment tools used, we found that these were not always used effectively or accurately. (See requirement 2 below) Care plans had not always been reviewed and updated as residents' needs or circumstances changed. (See requirement 2 below) Levenhall Nursing Home, page 19 of 39

Some care plans did not give enough information about what residents' needs were, or how staff were to provide care to meet those needs. For example, in one care plan for someone who was underweight there was nothing about their weight in their care plan for eating and drinking. Additionally, there was no guidance for staff about what foods the resident liked and which might tempt them to eat more, or how calories could be promoted in their diet. (See requirement 2 below) We also observed during lunchtime that residents were not assisted to sit in positions which would have made eating easier. We also observed that two residents who were of low weight did not eat all of their meal, but staff did not try to encourage them or offer an alternative. (See requirements 2 and 3 below) We also found that there was little effective evaluation of care plans, to consider if they were helping residents to achieve their goals, or if there was more that could be done to help them to do this. (See requirement 2 below) We asked staff if residents who were underweight were offered snacks of food that might tempt them to eat at regular intervals during the day. Staff told us this was not normally done, and the cook confirmed that, while she would be happy to provide snacks she was not asked for them. (See requirement 2 below) We noted during our visit that few residents had drinks made available to them in between set meal or snack times. One relative who completed our questionnaire also commented on this. Although there were water coolers in the lounges, these were not accessible to residents with mobility difficulties, and we did not see glasses of juice or water being offered to residents. For older residents with dementia, water coolers may not be familiar objects, and so would not prompt them to ask for a drink. The visual prompt of a water jug or tumbler within reach would be a more effective prompt to take a drink. (See requirement 3 below) We saw that a sensor mat had been placed at the entrance to the lounge upstairs, and when we asked why we were told that it was to alert staff if one resident, who was known to be at risk of falling, left the room. We had concerns about not only the effectiveness of this in ensuring this resident's safety, but the issue of using a method of restraint which affected all residents in that lounge in order to meet the needs of one resident. Legislation in relation to the use of restraint for safety reasons states that any restraint should be used as a last resort, and should be the least intrusive method possible for ensuring the person's safety. We assessed that, in the circumstances described to us, the use of the sensor mat in this way would not effectively protect the resident at risk of falling, and this could best be addressed by increased supervision in the lounge. We also judged that it was inappropriate to apply restraint to everyone who used this lounge. (See requirement 4 below) We could see from care records that a review of care, involving the family of a resident as well as their social worker, had taken place for one resident in November Levenhall Nursing Home, page 20 of 39

2011. However there were no notes of what what was discussed at this review, or what action was required. This meant that any actions had been delayed from November until the time when our visit took place in January 2012. (See requirement 2 below) Although, as noted above, records of medication administration had improved since the last inspection carried out by the Care Commission, we noted that there was some lack of clarity over the signature of one member of staff, who signed their name with just one initial. It was not clear when this was the staff member's signature, or when it was a code used to indicate that the resident had declined their medication. A list of staff signatures should be available with the medication records, and signatures should be clearly distinguishable. (See recommendation 1 below) We asked to see training records so that we could see what training staff had received to provide them with suitable skills and knowledge to meet residents' health and wellbeing needs. The Manager told us that all training certificates were kept in individual staff files, and there was no system in place to give an overview of what training had been provided, or to keep track of training needs either for individual members of staff, or for the whole staff team. (See requirement 3 in Statement 2 of Quality of the Environment, and recommendation 2 below) Grade awarded for this statement: 3 - Adequate Number of requirements: 4 Number of recommendations: 2 Requirements 1. The Provider must, having regard to the size and nature of the service, the statement of aims and objectives, and the number and needs of service users, ensure that there are at all times sufficient staff working in the service to meet the needs of service users. In order to do so, the Provider must: carry out accurate assessments of service user dependency levels and submit these to the Care Inspectorate for consideration; carry out accurate assessments of service user dependency levels on a 4 weekly basis, and use these assessment to plan the numbers and deployment of staff working in the service throughout the 24 hour period. Dependency assessments must include consideration of individual service user's social and leisure needs as well as the layout of the accommodation in the service; record and be able to evidence how those dependency assessments are used to inform staffing levels and deployment. Levenhall Nursing Home, page 21 of 39

This is in order to comply with SSI 2011/210 Reg 15(a) - a regulation regarding staffing. It is also in accordance with the National Care Standards Care Homes for Older People Standard 5.7, and the SSSC Code of Practice for Employers Section 1.5. Timescale for implementation: the assessment of dependency levels must be submitted to the Care Inspectorate within 3 weeks of publication of this report. Other assessments as detailed above must be ongoing. 2. The Provider must make proper provision for the health, welfare and safety of serviced users. In order to do so, the Provider must review personal plans to ensure that: care plans reflect the aims, wishes, needs and preferences of the individual resident; assessment tools are used accurately to identify service users' needs; care plans identify all of the individual service user's needs, and clearly demonstrate how those needs are to be met, specifically but not exclusively in relation to eating and drinking; care plans are effectively evaluated to ensure they are meeting the identified aims and goals of the individual service user; care plans are updated to reflect changes in service users' needs or circumstances, and in response to actions identified as part of a review of care or advice or instruction given by healthcare professionals or other agencies with a professional interest in the service user's care. This is in order to comply with SSI 2011/210 Reg 4(1)(a) - a regulation regarding the welfare of users, and Reg 5(1), 5(2)(i) and 5(2)(ii) - regulations regarding personal plans. It is also in accordance with the National Care Standards Care Homes for Older People Standard 5.4 - Management and Staffing Arrangements, Standard 6 - Support Arrangements, Standard 8.1 - Making Choices, Standard 9.2 - Feeling Safe and Secure, Standard 14 - Keeping Well, Healthcare, the SSSC Code of Practice for Employers Sections 1.5 and 2.2, and the SSSC Code of Practice for Social Service Workers Sections 1.1 and 6.1, the NMC Guidance for the Care of Older People 2009, and the Scottish Government Standards for Dementia Care in Scotland 2011. 3. The Provider must make proper provision for the health, safety and wellbeing of service users. In order to do so the Provider must: ensure that residents have easy access to a range of hot and cold drinks throughout the day, and as appropriate during the night; Levenhall Nursing Home, page 22 of 39

ensure that residents with cognitive impairment have visual and verbal reminders to drink regularly, and are helped and supported to do so; ensure that residents receive all necessary assistance at mealtimes in order to improve their dining experience and encourage them where appropriate to maximise their dietary intake. This is in order to comply with SSI 2011/210 Reg 4(1)(a) - a regulation regarding the welfare of users. It is also in accordance with the National Care Standards Care Homes for Older People Standard 6 - Support Arrangements, Standard 13 - Eating Well, the SSSC Code of Practice for Social Service Workers Section 6.1, and the NMC Guidance for the Care of Older People 2009. Timescale for implementation: Within 24 hours of receipt of the draft copy of this report, and ongoing. 4. The Provider must review the way methods of restraint are used in the service to promote the safety of individual service users. These must be used in such a way as meets current legal requirements and expected standards of good practice. All use of restraint should be recorded in line with the requirements set out in the relevant legislation. This is in order to comply with SSI 2011/210 Reg 4(1)(c) - a regulation regarding the welfare of users, and SSI 2011/28 Reg 4(1)(a) and (b) - regulations regarding records, notifications. It is also in accordance with the National Care Standards Care Homes for Older People Standards 5.4 and 5.11 - Management and Staffing Arrangements, Standard 6.1 - Support Arrangements, Standard 9.8 - Feeling Safe and Secure, Standard 17.5 - Daily Life, The Mental Welfare Commission Rights, Risk and Limits to Freedom, the SSSC Code of Practice for Social Service Workers Sections 1.1, 1.3 and 6.1, the NMC Guidance for the Care of Older People 2009, and the Scottish Government Standards for Dementia Care in Scotland 2011. Timescale for implementation: Within 24 hours of receipt of the draft copy of this report, and ongoing. Recommendations 1. The Provider should ensure that signatures to record the administration of medication administration are clear and unambiguous. A record of staff signatures for those staff members responsible for medication administration should be kept alongside the medication administration records. Levenhall Nursing Home, page 23 of 39

This is in accordance with the National Care Standards Care Homes for Older People Standard 5.4 - Management and Staffing Arrangements, the SSSC Code of Practice for Employers Sections 1.5 and 2.2, and the SSSC Code of Practice for Social Service Workers Section 6.2. 2. The Provider should put into place a system for recording the training that staff have undertaken which enables the management to monitor staff training, identify training needs for individual staff members or groups of staff, and to plan a programme of training to meet those needs. This is in accordance with the National Care Standards Care Homes for Older People Standard 5.4 - Management and Staffing Arrangements, and the SSSC Code of Practice for Employers Sections 1.5 and 2.2. Statement 5 We respond to service users' care and support needs using person centered values. Service strengths Much of the information in Statements 1 and 3 of Quality of Care and Support is also relevant to this Statement. As we noted previously, interactions that we saw between staff and residents were polite and respectful. We saw that when they had time, staff stopped to chat with residents. When we spoke with staff we found that they knew the residents well as individuals, and were aware of some of the things that were important to them in their daily lives. We saw that there was some information in care plans which was specific to the individual resident. Areas for improvement We saw that staff were often limited in the time they had to spend with residents because they were busy with tasks of care. This meant that they were not always able to respond to residents needs in a way which reflected the choices and preferences of each resident. An example of this is the way that bathing arrangements were planned and allocated. (See requirement 1 in Statement 1 of Quality of Care and Support) As we noted earlier, the music being played in the upstairs lounge during our visit was constant and did not vary during the morning. The volume of the music made conversation difficult. We observed how residents were assisted with their meals at lunchtime. While staff were busy attending to residents, interactions were neutral rather than positive. For example, staff said "Here's your lunch Mr X" when putting a plate on the table, or "A wee bit more Mrs X" when assisting a resident to eat, but there was little conversation. When we gave feedback about this after the inspection, Levenhall Nursing Home, page 24 of 39

the Manager told us that staff felt awkward because they were aware that they were being observed, and we recognised that this could be stressful for staff. (See requirement 1 below) We described in Statement 1 how staff were allocated to work in one area of the Home during the morning, and another during the afternoon. When we asked why this was done, there was no reason identified. We discussed with the Manager the benefits, particularly for people with dementia, of having consistency in the staff providing their care throughout the day. (See requirement 1 below) As we noted earlier, we found that care plans were not person centred. The aims set out in care plans did not reflect the goals of residents, and there was often very little information about individual wishes or preferences. Some care plans we saw had general statements, which did not guide staff to provide care in a way which was specific to the individual residents needs, wishes or circumstances. (See requirement 2 in Statement 3 of Quality of Care and Support) Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 0 Requirements 1. The Provider must provide the service in a way which respects the dignity of service users, and affords them choice. In order to do so, the Provider must: review the way staff are deployed to ensure that this is done in the way most appropriate to the service users' needs; review the arrangements for support and supervision in the lounges to ensure that they reflect service users choices and preferences; provide training for staff on best practice in dementia care, to help them to recognise and understand the individual needs and abilities of residents with dementia, and to provide care in a more person centred way. This is in order to comply with SSI 2011/210 Regs 3 and 4(1)(b) - regulations regarding principles, and the welfare of users. It is also in accordance with the National Care Standards Care Homes for Older People Standard 5.3, 5.4 - Management and Staffing Arrangements, Standard 7.1 and 7.2 - Moving In, Standard 8.1 - Making Choices, Standard 10 - Exercising Your Rights, the NMC Guidance for the Care of Older People 2009, the Scottish Government Standards for Dementia Care in Scotland, and the SSSC Code of Practice for Social Service Workers Sections 1.1, 1.3, 1.4, and 3.1. Levenhall Nursing Home, page 25 of 39

Timescale for implementation: Within 24 hours of receipt of the draft copy of this report. Levenhall Nursing Home, page 26 of 39

Quality Theme 2: Quality of Environment Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths Much of the information in Statement 1 of Quality of Care and Support applies also to this Statement. In that Statement we set out the ways that the service created opportunities for residents and relatives to express their views, and how we saw that those views had been taken into account. We could see from photographs and records that some of the suggestions that residents and relatives had made had been put into place throughout the year. We could see that residents and relatives were consulted about how the environment of the Home was used for activities, and the kind of activities they wanted. We could see that residents and relatives had been involved in the self assessment of the service, including questions about the physical environment in the Home. Areas for improvement In Theme 1, Quality of Care and Support, we described some of the practice we observed that demonstrated that residents were views and choices were not always taken into account in relation to the environment of the Home, and how it was used. (See Requirement 1 in Statement 1 of Quality of Care and Support, Requirements 2 and 4 in Statement 3 of Quality of Care and Support, and Requirement 1 in Statement 5 of Quality of Care and Support) Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths There were a number of policies in use in the service to promote a safe environment. These included: Levenhall Nursing Home, page 27 of 39