Cumbrae House Care Home Service Adults 4-18 Burnbank Terrace Glasgow G20 6UQ Telephone:

Cumbrae House Care Home Service Adults 4-18 Burnbank Terrace Glasgow G20 6UQ Telephone: 0141 332 5909 Inspected by: Alison McEleny Type of inspection: Unannounced Inspection completed on: 20 September 2011

Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 6 3 The inspection 10 4 Other information 23 5 Summary of grades 24 6 Inspection and grading history 24 Service provided by: Lambhill Court Ltd Service provider number: SP2003002359 Care service number: CS2010270797 Contact details for the inspector who inspected this service: Alison McEleny Telephone 0141 843 4230 Email enquiries@scswis.com Cumbrae House, page 2 of 25

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 3 Adequate Quality of Management and Leadership 3 Adequate What the service does well The organisation had a Participation Strategy. Residents and relatives had been involved in care reviews, a meeting and some questionnaires. Personal plans viewed contained a good level of detail in relation to residents' care needs. Activities were planned within the home including a weekly outing, by the activity organiser who commenced in August 2011. The current staff rotas indicated a recent increase in the day shift care staff which provided a reasonable number of staff on duty on all shifts and included one nurse. A minimum level of domestic/laundry and catering staff were in place. Staff had been good at recording any repairs which were required and these were signed off quickly by the maintenance team. Staff recruitment files viewed reflected an overall adequate recruitment and induction processes. Some staff meetings and training were evident. Cumbrae House, page 3 of 25

What the service could do better Inspection report continued It was acknowledged that the occupancy of the home was increasing gradually and that most participation processes were still to be introduced. Two of the personal plans viewed did not contain consistent or detailed information throughout. Staffing needed to be continually reviewed in relation to the skill mix of nursing and care staff; domestic and laundry staff. The procedure for accident and incident reporting after the forms had been completed needed to be clarified and monitored. It was evident that not all monthly maintenance checks had been recently undertaken. The organisation needed to ensure that appropriate checks had been received prior to any applicant starting work in the service. A robust induction programme for new staff should be in place. The management of the service had not been maintained since the manager had left in mid June 2011. What the service has done since the last inspection This was the first inspection since registration in December 2010. Conclusion The service had been steady in admitting new residents and increasing their occupancy level. The management of the service had been inconsistent since mid June 2011. The senior management had acknowledged the areas for improvement and were taking corrective action. Who did this inspection Alison McEleny Lay assessor: n/a Cumbrae House, page 4 of 25

1 About the service we inspected Cumbrae House Care Home is registered to provide nursing care and support for a maximum of 66 Older People. The accommodation has been converted from an existing care home premises comprising of three floors with lift access between them. All bedrooms are single with ensuite shower facilities. The home is situated in a residential area, has a car park and secured garden area to the rear. There are shops and other facilities nearby. Before 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 (SCSWIS), took over the work of the Care Commission, including the registration of care services. This means that from 1 April 2011 this service continued its registration under the new body, SCSWIS. The home aims to provide 'the highest standard of care and to do everything to make people's stay as pleasant and as comfortable as possible'. 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 - Grade 3 - Adequate Quality of Management and Leadership - Grade 3 - Adequate 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. Cumbrae House, page 5 of 25

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 This report was written following an unannounced inspection which was carried out on the 7 and 20 September 2011 between 10.00am and 7.00pm. Feedback was provided to the management team at the end of the inspection visit. As requested by us, the care service sent a self assessment. An Annual Return was not required from the service as this was the first inspection since registration. We issued questionnaires for residents and relatives. Two completed questionnaires were returned before the inspection. In this inspection we gathered evidence from various sources, including the relevant sections of policies, procedures, records and other documents, including: - Staff practice - Staff recruitment files - Resident personal plans - Staff meetings and training records - Accident and incident records - Maintenance records - Staff rotas - Observation of the environment - Discussions with residents, relatives, staff and manager. 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 Cumbrae House, page 6 of 25

Inspection Focus Areas (IFAs) Inspection report continued 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 Cumbrae House, page 7 of 25

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: No 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. We received a completed self assessment document from the service provider. We were satisfied with the way the service provider had completed this and with the relevant information they had given us for each of the headings that we grade them under. The detail submitted was brief but reflected the service being provided. The service provider identified what they thought they did well, the areas for development and any changes they planned. The service provider told us how the people who used the care service had taken part in the self assessment process. Taking the views of people using the care service into account Five residents were spoken with during the inspection visit. They agreed that they were happy with the overall quality of care received. Some comments received were: 'I like sitting here its very pleasant' 'staff are good company, have a wee blether with them' 'they look after me here, the food's quite good' 'I like the home baking that we get in the afternoon' Taking carers' views into account Two questionnaires were returned from relatives. They agreed that they were happy with the overall quality of care received. Some comments received were: 'my family are very happy with the care and attention my relative is receiving' 'staff are patient when my relative tries to speak with them' 'Cumbrae House are very attentive with dignity and respect' Cumbrae House, page 8 of 25

One relative spoken with during the inspection visit discussed recent concerns in relation to their relative's care. This was discussed with management at the feedback meeting. Cumbrae House, page 9 of 25

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 Overall 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 organisation had a Participation Strategy. It was indicated that participation was being carried out with individual residents and their relatives during the moving in process. The service's information booklet contained a Residents Charter which stated that residents and their relatives would be actively encouraged to participate in planning care. Questionnaires had been issued to some residents and visitors in April 2011. The questions were in relation to the care provided, staff attitudes, environment and communication. All received positive feedback and in particular those relating to staff and the manager. The first residents and relatives meeting had been held on 24 August 2011. The depute, activities staff, chef and laundry staff were present at the meeting with about 10 residents and relatives. The minutes of care reviews seen, reflected the involvement of residents and their families although most were social work reviews following moving in. Areas for improvement None of the questionnaires issued in April 2011 were signed or dated. Questionnaires could have been issued to residents and relatives on an ongoing basis shortly after moving in. The minute of the resident and relative meeting reflected the giving of information but not any discussion with those present. Residents and relatives should be made aware of the dates for future meetings. Cumbrae House, page 10 of 25

The service's self assessment indicated the development of resident and relative meetings, questionnaires and involvement in recruitment of staff. It was acknowledged that the occupancy of the home was increasing gradually and that most participation processes were still to be introduced (see Recommendation 1). Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The organisation's Participation Strategy should now be fully implemented. National Care Standards for Care Homes for Older People: Standard 11 - Expressing your views and Standard 17 - Daily life. Cumbrae House, page 11 of 25

Statement 3 We ensure that service user's health and wellbeing needs are met. Service strengths Four personal plans were viewed in relation to the care that residents received. There were various risk assessments and care plans for the needs identified including social and mental health. There was evidence of relevant health professionals being involved where required such as GP, falls team, psychiatric staff and liaison nurse. There was a six monthly care review matrix in place with planned and actual dates. Most residents had received their four week social work review with six monthly reviews planned to start in October 2011. A pictorial activities planner was displayed on the ground floor. Morning exercises were planned every morning reflecting the provider's belief in the physical and mental benefits of exercise. Other activities planned included a weekly afternoon outing, cooking and a sing-a-long. Photos of a recent barge trip were seen and during the inspection visits, the cooking and singing was taking place with a few of the residents in ground floor lounge. The chef was spoken with briefly. The organisation provided a four week menu which included home baking and had been nutritionally assessed by a dietician. Local changes could be made in each home. He completed food preference records with every resident. These were seen and had been completed shortly following the residents' admissions. Staff had a daily planner and report sheet. The planner recorded what care staff were allocated to do each day and the report sheet, which included all departments, highlighted any issues for that day. Areas for improvement Two of the personal plans viewed did not contain consistent information throughout the plan with the result that some information was contradicting. There was no reflection of the number of falls in one care plan evaluation and the other personal plan did not contain specific detail of how the resident's behaviour was to be managed (see Recommendation 1). It was not clear if the daily planner was being used every day or to it's full potential ensuring that all residents needs were met. Most of the entries in the daily report sheet were not very specific and there were a lot indicated as 'ongoing' or blank such as for 'training', 'meetings', 'reviews'. The management stated that this had now been replaced by '10am meetings' which a representative from all departments attended on a daily basis. They were asked to Cumbrae House, page 12 of 25

ensure that these meetings continued even when a manager was not present within the home such as one morning a week and at weekends. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. All personal plans should contain up to date and consistent information throughout the plan. National Care Standards for Care Homes for Older People: Standard 6 - Support arrangements. Cumbrae House, page 13 of 25

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 The methods of service user participation reported in statement 1.1 remain relevant for this statement. The service's information booklet and the Residents Charter also stated that residents could bring personal belongings including items of furniture to create a familiar homely surrounding. Bedrooms viewed were personalised with ornaments, family photographs and some had their own furniture. The service's self assessment also reflected that there was a choice of available rooms, could change the furniture and colour. Areas for improvement The areas for development reported in statement 1.1 remain relevant for this statement. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Cumbrae House, page 14 of 25

Statement 2 We make sure that the environment is safe and service users are protected. Service strengths Observations of the home showed that the décor and furnishings of the home had been maintained with all areas clean and tidy. The residents clothing seen in the laundry was all named. Residents were seen to be walking freely around their unit and sitting either in their bedrooms or in areas provided in the corridors. Staff were visible throughout the home with good interaction between all staff and residents. As stated previously, the occupancy of the home was increasing gradually and therefore did not have a full complement of staff. The first residents had been admitted in March 2011 and currently there were twenty-nine residents, fifteen of which were receiving nursing care and three receiving respite care. The current staff rotas indicated a recent increase in the day shift care staff which provided a reasonable number of staff on duty on all shifts and included one nurse. A minimum level of domestic/laundry and catering staff were in place. An activity organiser had commenced in the home at the beginning of August 2011. The service kept an indexed record of any accidents and incidents which occurred. Staff had completed forms following each occurrence with all forms being signed off by management and containing follow up action. The maintenance and housekeeping staff had daily checklists and these were found to be up to date. The maintenance team visited the home a minimum of once a week or as required for more urgent issues. Staff had been good at recording any repairs which were required and these were signed off quickly by the maintenance team. Areas for improvement The current staff rotas did not reflect any senior care staff. The domestic/laundry staff worked approximately fifty-five hours overtime every week to provide the minimum levels required which did not include any evening cover. The chef worked eight hours a week overtime. The current management time stated that senior care staff would be transferred from other homes within the organisation and bank staff would be used to reduce the domestic/laundry staff overtime hours including changing the shifts to include evening cover. It was noted, on the second visit, that a new domestic/laundry staff member had started their induction (see Requirement 1). The procedure for accident and incident reporting after the forms had been completed was not clear. A folder in the manager's office did not contain the same completed forms that were found in a folder in the ground floor staff office. The overview and audit processes were also not clear. One of the current managers acknowledged that the procedure that should be in place was not and a memo was issued to all staff, during the inspection, to clarify the procedure. This stated that: Cumbrae House, page 15 of 25

* all forms must be submitted to the manager for review * these would then be returned with actions for staff to implement * returned forms must be stored in the residents care file along with the falls risk assessment * a falls diary must be implemented where the resident has had more than two falls * a care plan must be implemented to reflect the level of falls * a monthly action plan will be completed by staff for the manager The tool to be used to audit accidents and incidents was viewed. This would be completed on a monthly basis and highlight the overall number of occurrences; individual residents with more than one occurrence; the time, place and type of occurrence (see Requirement 2). It was evident that not all monthly maintenance checks had been recently undertaken. Hot water temperatures had been recorded up to the end of June 2011 and profile bed checks up to the end of July 2011 (see Requirement 2). Although repairs were signed off quickly, the record did not give any details as to what action had been taken. The Daily Report Sheet for 22 August 2011 stated that there had been 'no heating over the weekend'. There was no entry in the maintenance record of the issue or of what action had been taken. The current management indicated that they were not aware that this issue had occurred (see Requirement 2). Grade awarded for this statement: 3 - Adequate Number of requirements: 2 Number of recommendations: 0 Requirements Inspection report continued 1. All staffing levels must be continuously monitored and increased where required to ensure residents safety and that their care needs are met. This is to comply with: SSI 2011/210 Regulation 4: Welfare of users and Regulation 15: Staffing. Timescale: within 24 hours of receipt of this report. 2. Any procedures in place to ensure the safety of residents must be followed and the relevant records completed in full. This is to comply with: SSI 2011/210 Regulation 4: Welfare of users. Timescale: within 24 hours of receipt of this report. Cumbrae House, page 16 of 25

Quality Theme 3: Quality of Staffing Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths The methods of service user participation reported in statement 1.1 remain relevant for this statement. Areas for improvement The areas for development reported in statement 1.1 remain relevant for this statement. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Cumbrae House, page 17 of 25

Statement 2 We are confident that our staff have been recruited, and inducted, in a safe and robust manner to protect service users and staff. Service strengths Three staff files were viewed in relation to recruitment. All contained a completed application form, interview notes, a right to work in the UK confirmation and relevant training information. Two files contained two written references from relevant persons and one had evidence of a Protection of Vulnerable Group (PVG) check being carried out. All the above checks had been received prior to the applicant starting work in the service. Induction/orientation and fire precaution awareness checklists had also been completed in all files. Areas for improvement One file did not contain written references from relevant persons and two files did not clearly evidence that PVG checks had been carried out. One of the current managers had completed a PVG risk assessment in one file and had been in contact with Disclosure Scotland to rectify the situation (see Requirement 1). All interviews had been carried out by one interviewer. A minimum of two interviewers would be good practice. All induction/orientation checklists had been completed on the employee's first or second day. It covered a number of the organisation's policies and procedures. It was not clear what information was given or how and who had been allocated as the staff's mentor. The management advised that the organisation was developing a robust induction programme to be carried out over the three month probationary period (see Recommendation 1). Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 1 Requirements 1. The organisation must have a robust recruitment procedure in place to ensure that appropriate checks have been received prior to any applicant starting work in the service. This is to comply with: SSI 2011/210 Regulation 9: Fitness of employees and Regulation 4: Welfare of users. Timescale: within 24 hours of receipt of this report. Cumbrae House, page 18 of 25

Recommendations Inspection report continued 1. The organisation should develop and implement a robust induction programme for new staff. National Care Standards for Care Homes for Older People: Standard 5 - Management and staffing arrangements. Cumbrae House, page 19 of 25

Quality Theme 4: Quality of Management and Leadership 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 management and leadership of the service. Service strengths The methods of service user participation reported in statement 1.1 remain relevant for this statement. Areas for improvement The areas for development reported in statement 1.1 remain relevant for this statement. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Cumbrae House, page 20 of 25

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 The manager who had been in post when the service was registered had left in mid June 2011. The depute and other management within the organisation were overseeing the operation of the service till a new manager was appointed. Minutes of staff meetings in April and July 2011 were seen. The April minutes showed discussions about staff roles; residents care needs; care documentation and staff practice. Minutes of senior management visits in April, June and July 2011 were seen. There were discussions about current occupancy and staffing levels; care documentation and residents needs; activities; domestic/laundry duties as well as a walk round in the service. Minutes of the '10am meetings' commenced in September 2011 were seen. The minute for 20 September showed discussions about resident and staff numbers; any issues about staffing; any maintenance issues; the planned activity and any resident health concerns. A training plan for May to December 2011 was in place and Customer Care training had been provided by the depute in May 2011 for seven staff. Questionnaires about the content of the training were completed following the session. Some staff had also received other training which was provided throughout the organisation from May to August such as fire, food hygiene, Moving and Assisting. Eight staff had held a supervision meeting with the depute in April and May 2011. The service kept a record of any complaints received. Records showed that complaints had been resolved following investigation and responds had been within required timescales. Areas for improvement As previously stated, most of the organisational monthly checking and monitoring systems that were in place had not been completed since June 2011. These included: * hot water temperatures * profile bed records * residents weights and special diets. It was not evident that the other training identified on the training planner had been carried out. The service's self assessment had indicated, in various statements, that Cumbrae House, page 21 of 25

training was an area for improvement. No further supervision meetings had been held with staff since May 2011. The previous manager had carried out a partial audit in April 2011. It was indicated that a medication audit had also been carried out recently but this was not available during the inspection visits. Concerns about the management and related care were received prior to the inspection visits. The Social Work Department carried out investigations involving the relevant residents and their families. It was evident that the management of the service had not been maintained since the manager had left in mid June 2011 (see Requirement 1). The organisation had responded to recent concerns by providing management cover five hours a day between Monday and Friday by two of their other service managers. They were clear about their remit in relation to assessing what areas needed to be improved. Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 0 Requirements 1. The management of the service must always be maintained. This is to comply with: SSI 2011/210 Regulation 4: Welfare of users. Timescale: within 24 hours of receipt of this report. Cumbrae House, page 22 of 25

4 Other information Complaints No complaints have been upheld, or partially upheld, since the registration of the service. Enforcements We have taken no enforcement action against this care service since the registration of the service. Additional Information n/a Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). Cumbrae House, page 23 of 25

5 Summary of grades Quality of Care and Support - 3 - Adequate Statement 1 Statement 3 3 - Adequate 4 - Good Quality of Environment - 3 - Adequate Statement 1 Statement 2 3 - Adequate 3 - Adequate Quality of Staffing - 3 - Adequate Statement 1 Statement 2 3 - Adequate 3 - Adequate Quality of Management and Leadership - 3 - Adequate Statement 1 Statement 4 3 - Adequate 3 - Adequate 6 Inspection and grading history All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Cumbrae House, page 24 of 25

To find out more about our inspections and inspection reports Read our leaflet 'How we inspect'. You can download it from our website or ask us to send you a copy by telephoning us on 0845 600 9527. This inspection report is published by SCSWIS. You can get more copies of this report and others by downloading it from our website: www.scswis.com or by telephoning 0845 600 9527. Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: 0845 600 9527 Email: enquiries@scswis.com Web: www.scswis.com Cumbrae House, page 25 of 25