Dalawoodie House Nursing Home Care Home Service Newbridge Dumfries DG2 0QY Telephone: 01387 720 905 Type of inspection: Unannounced Inspection completed on: 25 May 2017 Service provided by: Downing Care Limited Service provider number: SP2013012042 Care service number: CS2013316350
About the service Dalawoodie House Nursing Home is a care home service, registered to provide care to a maximum of 36 older people with physical or sensory impairment and/or memory impairment or dementia. The provider is Downing Care Limited. The home is situated in a quiet location near Newbridge in Dumfries and Galloway. Accommodation is over two floors, with stairs, two passenger lifts and a chair lift to enable people to access the upper floor. All bedrooms are single rooms. Six bedrooms have en suite toilet. Shared bathroom and toilet facilities are available on both floors. There are two lounges on the ground floor. One of which has access to a pleasant garden area. A separate dining room is also on the ground floor. At the time of the inspection 26 people were living in the home. The aim of the service is "to be the preferred choice for nursing and residential care in Dumfries and Galloway." The provider's philosophy of care includes aiming "to provide a service which promotes independence and gives encouragement to lead an active and full life as far as age and health allows." What people told us We spoke with five service users during out inspection visit. All indicated satisfaction with the service and could not think of anything which could improve the service further. We issued 10 questionnaires for relatives and three were completed. All three "strongly agreed" that overall they were happy with the quality of care for their relative. In addition we spoke with seven relatives. All gave positive feedback on the quality of care provided Some felt that communication had been problematic at times but this was improving. There were no issues raised regarding the environment or facilities available. Two relatives felt at times it was hard to find staff and this gave concern as some residents were left unobserved for periods of time. All were aware a new manager had come into post and that changes were being made to improve the service. page 2 of 16
Self assessment The service had not been asked to complete a self assessment in advance of the inspection. We discussed the development of a home improvement plan and quality assurance paperwork. These were being developed in order to show how they were monitoring of the quality of the provision within the service. This will be checked at the next inspection. From this inspection we graded this service as: Quality of care and support Quality of environment Quality of staffing Quality of management and leadership 3 - Adequate 3 - Adequate 3 - Adequate 3 - Adequate Quality of care and support Findings from the inspection Residents and relatives we spoke with were complimentary about the quality of care and support provided. We observed resident's personal appearance and all were well kept. We examined five personal plans which gave details of personal care and preferences to help staff to meet individual needs. The personal plan records included a one page profile that helped staff see easily essential care and support needs. Medication records were examined and some issues of medication management had already been identified by staff. An action plan was in place of how this would be improved. Progress will be checked at the next inspection. Based on observations of staff responses to residents with distressed behaviours calling out for attention we concluded improvements could be made. Staff understanding of this subject should be developed and changes made to ensure residents can be heard and responded to, to minimise these negative situations. Residents with distressed behaviours could have these better described and recorded in the personal plans as to what the triggers are and the actions which help to reduce. Although charts were available to help monitor stress and distress these were not always used to best effect and this should be improved in order to improve the outcome for service users. See recommendation 1. Personal plan reviews were in progress involving social workers if necessary. However, we could not see the direct involvement of relatives or others with legal responsibility to ensure the plans of care had been discussed and agreed. The review format could be improved further to ensure care plans are agreed and updates are made to important records such as adults with incapacity certificates, do not attempt resuscitation documents and advance care plans. See recommendation 2. page 3 of 16
Residents weights were being monitored and there was no evidence of nutritional needs not being met. However, the mealtime experience should be improved in terms of how this is managed by staff and the quality of food presentation. It was agreed a heated trolley would be provided and this would help to make immediate improvements. See recommendation 3. Some residents were assessed by the local authority as requiring nursing care and others were defined as "residential". This was not always clear to staff and recorded in the personal plans. This is important so that staff know their roles and who to contact if nursing care is needed. It could also be clearer in the personal plans which professionals are involved by clearly recording their contact details. Requirements Number of requirements: 0 Recommendations Number of recommendations: 3 1. The service provider should ensure residents with stress/ distress are responded to readily by staff and best practice is followed in terms of assessment and record keeping. National Care Standards for care homes for older people, Standard 5.4 Management and Staffing arrangements. 2. The service provider should ensure personal plans show evidence of involvement and agreement by the resident/ legal representative or next of kin. The 6 monthly review format should be further improved to ensure important documents are kept up to date such as adults with incapacity certificates, do not attempt resussatation and advance care plans. National Care Standards for care homes for older people, Standard 6.3 Supporting Arrangements. 3. The service provider should improve the mealtime experience for residents. This should be based on best practice to ensure food is served attractively and residents are assisted appropriately. National Care Standards for care homes for older people, Standard 13 - Eating Well. Grade: 3 - adequate Quality of environment Findings from the inspection We found there was a welcoming and friendly atmosphere, and the environment was generally pleasant and homely. Family members were welcomed at all times. Visitors we spoke with commented positively about the friendly welcome they received when they visited. We saw the home was clean and tidy; both residents and relatives commented positively about the cleanliness of the home. page 4 of 16
We saw maintenance records were up to date and appropriate systems were in place to monitor safety and cleanliness. There was a well-maintained garden area and we saw residents and their families enjoyed its use. The home is located in a rural setting and some residents were supported to attend local events through the use of taxis. The facilities for bathing and showering were in progress of being updated on the ground floor. We saw there were no supportive showering facilities available for residents with higher dependency. A fixed height bath was available. This was discussed with the manager and it was agreed it would be beneficial to see facilities being improved. At present most bedrooms lack en-suite facilities and there is regular use of commodes. This is less dignified than toilet use and a long term strategy to improve the facilities should be developed. The layout of the home means that lounges are often left unsupervised for periods of time. The deployment of staff and further use of assistive technology could make additional improvements to the safety of residents. See staffing theme 3 recommendation 1. The storage of valuable items was in a locked box in resident's bedrooms. This was usually stored in wardrobes. For security all residents should have the option of a lockable space within their bedroom or another suitable option made available. There was an on-going plan of refurbishment and redecoration in the home. We recommend the use of The King's Fund Environmental Assessment Tool, and other best practice guidance, to inform this plan and evaluate if the care home was dementia friendly. This should inform the refurbishment plan and take into account the need to improve the facilities over the longer term to provide care with increased dignity and privacy when needed. See recommendation 1. Requirements Number of requirements: 0 Recommendations Number of recommendations: 1 1. The service should use methods that reflect up-to-date knowledge and best-practice guidance to inform the plan of refurbishment and redecoration in the home in order to meet the needs of older people with dementia. A copy of this plan should be shared with the Care Inspectorate. National Care Standards - Care Homes for Older People - Standard 4.1 - Your Environment & Standard 5.4 Management and staffing arrangements. Grade: 3 - adequate Quality of staffing page 5 of 16
Findings from the inspection In our observations of staff most practice was respectful, warm and positive. We saw trusting relationships had developed between residents and staff. The manager was keen to further develop and maintain these positive interactions through the use of staff observations to provide staff with immediate feedback on what works well and what could be developed further. The staff team had received some training opportunities to improve the quality of dementia care. Two staff were identified as dementia ambassadors, to identify areas for improvement in dementia care and to facilitate specific learning on this subject. As yet the impact of this was still in the early stages and further development of these roles was needed to ensure best practice was achieved. A varied training programme was in place for staff. This included management of falls, incident reporting and adult support and protection. Supervision sessions had started to provide staff with one to one time with a line manager. This meant some staff had personal development plans which gave the formal opportunity to reflect on and develop their practice in supporting residents with dementia. Regular team meetings had been introduced by the manager and staff told us this was proving beneficial in improving communication between the shifts and staff team generally. We observed staffing deployment at mealtimes to be too low and this had a negative impact on resident's dining experience. A small number of relatives commented on the lack of staff visibility around the lounge areas and at times this can cause concern for the safety of residents. We also observed periods of time which the lounges were unsupervised and saw records which indicated staff carried out checks on the lounges but sometime this could be an hour apart. We discussed this with the manager and recommended an evaluation of the general deployment of staff around the home, particularly at night, to better meet the needs of residents. See recommendation 1. There was only one part time senior carer on the staff team and this meant all of the leadership was provided by the nurse on duty. A review of staff roles to develop leadership amongst care staff would be beneficial. This could include a review of how staff organise and deploy themselves in order to better meet the needs of residents. See recommendation 2. Requirements Number of requirements: 0 Recommendations Number of recommendations: 2 1. The service provider should evaluate the deployment of the staff team to ensure that at all times the number of staff who are trained and who have the necessary skills will be sufficient to meet the support and care needs of people using the service. National Care Standards - Care Homes for Older People - Standard 5 'Management and staffing arrangements' page 6 of 16
2. The service provider should develop staff roles to ensure effective leadership in order to promote and deliver high quality care practices in order to meet the needs of residents. National Care Standards for care homes for older people, Standard 5.4 Management and staffing arrangements. Grade: 3 - adequate Quality of management and leadership Findings from the inspection Policies and procedures were in place with review dates to help ensure these were up to date and applicable. Systems within the home were being reviewed by the new manager and many changes were being made. A new quality assurance framework was being developed. We saw new audits had been introduced but the quality assurance policy did not set out clearly what the audit topics would be or the frequency they would be used to help monitor the quality of the service. See recommendation 1. The manager told us a new monthly reporting system would be introduced to provide an overview of key quality indicators such as number of complaints, incidents, audits, reviews and so on. See recommendation 2. The aims and objectives of the service would benefit from review to be clear as to who the service is for and to consider which standards and best practice guidance is applicable. For example the Standards for care for dementia in Scotland (2011). We discussed the benefits of a home development plan to set out priorities for improvement. There was a need to consider the environmental layout of the building and how this can be adapted to promote small group living and closer observation by staff of residents who walk around. Requirements Number of requirements: 0 Recommendations Number of recommendations: 2 1. The service provider should review the quality assurance policy and bring this up to date to reflect current practice in audit and other methods of monitoring the quality of the service such as monthly reports and the development of a home improvement plan. National Care Standards Care Homes for Older People: Standard 5 - Management and staffing arrangements. 2. The provider should ensure that information is gathered from audits, meetings, surveys and other ways, and that this is used to move the service forward. In order to do this they should: a) collate information gathered; page 7 of 16
b) devise action plans to implement any areas identified; c) work through devised action plans; d) re-visit action plans to ensure they have been completed; and e) feedback the outcomes to those who you have gathered the information from. National Care Standards Care Homes for Older People: Standard 5 - Management and staffing arrangements. Grade: 3 - adequate What the service has done to meet any requirements we made at or since the last inspection Previous requirements Requirement 1 The provider must make proper provision for the health, welfare and safety of service users and ensure that: a) adequate investigation takes place in relation to every fall to determine any trigger and/or cause; b) prompt action should take place after each fall to review whether any change to care and support is needed; c) record keeping must be improved to demonstrate that information collected and kept is accurate, sufficiently detailed and reflects the care planned or provided; d) there should be clear and accountable processes in place to make sure that appropriate monitoring takes place in relation to outcomes for each person; and e) staff require training in relation to their role in falls prevention, falls management and also their responsibility to keep clear, accurate and up to date records. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210), Regulation 4(1)(a). Timescale for completion: 15 May 2017. page 8 of 16
This requirement was made on 14 April 2017. New systems had been put in place to ensure new residents falls risks were identified and communicated to staff. Staff training had taken place on falls prevention and management. Monthly falls analysis was now in place and actions were being taken. Requirement 2 The provider must ensure that documents and records held in relation to residents are accurate and their content reflects the care actually provided. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210), Regulation 4(1)(a). Timescale for completion: 15 May 2017. This requirement was made on 14 April 2017. Personal plans had been updated and reviews with social work were almost completed. Improvements were seen to the accuracy and content of personal plans although further improvements were on-going. Requirement 3 The provider must ensure that residents' personal plans set out how their health, welfare and safety needs are to be met. In order to do this, the provider must ensure that all residents have personal plans which: a) accurately reflect all their current needs; b) include information about necessary care and support interventions and are developed to fully reflect the care being provided; c) contain risk assessments that are up to date; d) utilise the risk assessments to inform care planning; and e) reflect a person-centred approach and are developed in line with the National Care Standards. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210), Regulations 4(1)(a) and 5(1). Timescale for completion: 15 May 2017. page 9 of 16
This requirement was made on 14 April 2017. Personal plans had been updated and reviews with social work were almost completed. Improvements were seen to the accuracy and content of personal plans although further improvements were on-going. Requirement 4 The provider must: (a) ensure that no resident is subject to restraint, unless it is the only practicable means of securing the welfare and safety of that or any other resident and there are exceptional circumstances, and that unless restraint is being used in an emergency situation, that all necessary consents to the use of measures which may constitute restraint are in place; and (b) ensure that staff in the care service have access to and an understanding of the Mental Welfare Commission for Scotland guidance - Rights, risks and limits to freedom - relating to restraint issues. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210), Regulations 4(1)(a) and (c). Timescale for completion: 15 May 2017. This requirement was made on 14 April 2017. Staff training had taken place on Rights, Risks and Limits to Freedom. This had improved understanding of best practice. Staff training had also taken place on adult support and protection and there was improved understanding of these procedures. Further training was planned for staff on de-escalation. Discussion took place to encourage staff to use the Promoting Excellence training which has a module on stress/ distress. Equipment which may limit freedom such as bedrails had risk assessments present and new records of restraint records were in place to ensure such equipment was reviewed regularly. Personal plan audits could ensure this paper work is used consistently and checked at 6 monthly reviews. Requirement 5 The provider must: (a) carry out a review of staff skills and identify their training needs; (b) record the results of the review and the identified staff training needs in writing and provide a copy to the Care Inspectorate; and (c) develop a timescale plan to address any training needs identified by the review referred to at (a) above and provide a copy to the Care Inspectorate. page 10 of 16
Without prejudice to the generality of the foregoing, the review and plan referred to at (a) and (c) above must address: - (i) the use of measures which may constitute restraint (ii) adult support and protection (iii) risk assessment (iv) record keeping This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210), Regulation 15. Timescale for completion: 17 July 2017 with a progress plan for completion by 15 May 2017. This requirement was made on 14 April 2017. Staff observations had commenced to encourage good practice. Staff supervisions were in place and on-going development was planned in the staff training plan. Training had taken place on Rights, Risks and Limits to Freedom and Adult Support and Protection training had taken place. On-going development was planned with regards to risk assessment and record keeping. This will be monitored at future inspections. Requirement 6 The provider must ensure that all staff have training to ensure that they are aware that the reporting of serious incidents involving residents and staff need to be managed in line with the provider's policies and procedures and adult support and protection best practice guidance. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210), Regulation 15. Timescale for completion: 17 July 2017 with a progress plan for completion by 15 May 2017. This requirement was made on 14 April 2017. Information sessions had taken place for staff and incident reporting had improved. External support to the home had been provided by a Social Worker and District Nurse who both reported that incident reporting had improved and there was an improved understanding of adult support and protection policies and procedures. page 11 of 16
Requirement 7 The provider must improve the reporting systems and procedures when accidents and incidents occur, to safeguard vulnerable people and adhere to legal requirements. In order to do this the provider must: (a) demonstrate that practice is in line with legislation; (b) provide training so that staff follow policy and best practice about reporting accidents and incidents and are aware of their legal responsibility in keeping accurate records and retaining records; and (c) notify the Care Inspectorate of details of any incident that is detrimental to the health and welfare of a person using the service. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210), Regulations 4(1)(a). Timescale for completion: 17 July 2017 with a progress plan for completion by 15 May 2017. This requirement was made on 14 April 2017. Practice in incident reporting had improved, notifications had been made appropriately to the Care Inspectorate. Post incident analysis was now taking place. Requirement 8 The provider must improve the way accidents and incidents are audited and implement systems to assess, monitor and manage risks to residents. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210), Regulations 4(1)(a). Timescale for completion: 17 July 2017 with a progress plan for completion by 15 May 2017. This requirement was made on 14 April 2017. Investigations into incidents and accidents were taking place. Monthly analysis was carried out. External support was in place to consider improved use of assistive technology. Improved observation and use of alerts in the lounge areas will be encouraged and monitored at future inspections. Requirement 9 The provider must ensure that a service user's legal representative is informed timeously of any adverse incidents or accidents that impact on their health and welfare. The service provider must: a) Provide the care inspectorate with evidence of how this will be achieved. page 12 of 16
This is to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210), Regulation 4(1)(a). Timescale for completion: 20 May 2017. This requirement was made on 21 April 2017. Changes had been made at the service to help ensure good and timely communication took place with legal representatives and other agreed family members. We spoke with a relative of a resident who had a recent fall and injury and communication had taken place with the legal representative in the first instance and then with the other agreed family members. Staff were aware of their responsibilities. Requirement 10 The provider must make proper provision for the health, welfare and safety of service users and should: a) Demonstrate that all registered nursing staff employed in the service understand, comply and adhere to The CODE - Professional Standards of Practice and Behaviour for Nurses and Midwifes published by the NMC, 29 January 2015. b) Confirm with the Care Inspectorate that issues relating to the conduct of registered nursing staff highlighted in this complaint investigation have been referred to the NMC where necessary. This is to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI2011/210), Regulation 4(1)(a). Timescale for completion: 8 June 2017. This requirement was made on 10 May 2017. Nurses employed at the service had been reminded about their responsibilities to adhere to the NMC code of practice. Appropriate actions were taken by the service manager. page 13 of 16
What the service has done to meet any recommendations we made at or since the last inspection Previous recommendations Recommendation 1 The provider must ensure that residents' oral healthcare needs are met and: a) be able to evidence that staff are competent in the delivery of oral hygiene care; b) ensure that oral hygiene products are clean and stored correctly; c) ensure that oral hygiene risk assessments are accurately completed; d) ensure that records of oral hygiene care are accurately completed; and e) ensure staff understand the consequence of inaccurate record keeping. National Care Standards Care Homes for Older People: Standard 6 - Support arrangements. This recommendation was made on 14 April 2017. Action taken on previous recommendation Systems had improved to record oral hygiene had taken place. There was no evidence of poor oral hygiene. This recommendation is met. Recommendation 2 The provider should ensure that information is gathered from audits, meetings, surveys and other ways, and that this is used to move the service forward. In order to do, this they should: a) collate information gathered; b) devise action plans to implement any areas identified; c) work through devised action plans; d) re-visit action plans to ensure they have been completed; and e) feedback the outcomes to those who you have gathered the information from. National Care Standards Care Homes for Older People: Standard 5 - Management and staffing arrangements. This recommendation was made on 14 April 2017. Action taken on previous recommendation A new quality assurance system was being developed. New audits were being put in place. It was too early to gauge the effectiveness of this. Further development was needed. This will be checked at the next inspection. This recommendation is not met. page 14 of 16
Complaints Please see Care Inspectorate website (www.careinspectorate.com) for details of complaints about the service which have been upheld. Enforcement No enforcement action has been taken against this care service since the last inspection. Inspection and grading history Date Type Gradings 31 Mar 2017 Unannounced Care and support 2 - Weak Environment 2 - Weak Staffing 2 - Weak Management and leadership 2 - Weak 30 Sep 2016 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and leadership 2 - Weak 17 Sep 2015 Unannounced Care and support 3 - Adequate Environment 4 - Good Staffing 4 - Good Management and leadership 4 - Good page 15 of 16
To find out more This inspection report is published by the Care Inspectorate. You can download this report and others from our website. Care services in Scotland cannot operate unless they are registered with the Care Inspectorate. We inspect, award grades and help services to improve. We also investigate complaints about care services and can take action when things aren't good enough. Please get in touch with us if you would like more information or have any concerns about a care service. You can also read more about our work online at www.careinspectorate.com Contact us Care Inspectorate Compass House 11 Riverside Drive Dundee DD1 4NY enquiries@careinspectorate.com 0345 600 9527 Find us on Facebook Twitter: @careinspect Other languages and formats This report is available in other languages and formats on request. Tha am foillseachadh seo ri fhaighinn ann an cruthannan is cànain eile ma nithear iarrtas. page 16 of 16