Beechmount Care Home Service Adults 14 Ulundi Road Johnstone PA5 8TE Telephone:

Beechmount Care Home Service Adults 14 Ulundi Road Johnstone PA5 8TE Telephone: 01505 320274 Inspected by: Colin Goldie Type of inspection: Unannounced Inspection completed on: 20 May 2013

Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 11 4 Other information 24 5 Summary of grades 25 6 Inspection and grading history 25 Service provided by: Milbury Care Services Limited trading as Voyage Service provider number: SP2004005660 Care service number: CS2003001296 Contact details for the inspector who inspected this service: Colin Goldie Telephone 0141 843 6840 Email enquiries@careinspectorate.com Beechmount, page 2 of 27

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 5 Very Good Quality of Environment 5 Very Good Quality of Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well When talking to staff and reading support files we found that they were motivated, experienced and familiar with residents support needs and preferences. Staff were seen to make sure that residents were involved in the community and have their support needs met. Staff were seen to ask residents what they would like to do, such as going for walks, trips to the sea side or out for a meal. We saw that staff were responsive to residents changing needs and wishes. To make sure that people are appropriately supported Beechmount has its own accessible transport and large enclosed garden. What the service could do better There were some areas of the care home that required upgrading, for example the entrance hall carpet was worn and stained, ceiling wall paper in two bedrooms damaged and a bed base stained. We were informed that Voyage Care intends to refurbish the care home in 2013. This will be the subject of a recommendation. What the service has done since the last inspection There was one recommendation arising from the previous inspection. This has been met. Beechmount, page 3 of 27

Conclusion Inspection report continued Everyone spoken with during the inspection was very committed to making sure that Beechmount meets client's expectations and needs. When speaking with staff it was evident that they put client's best interests at the heart of all their work. We saw this when staff were working with residents and by reading support files. We thought that residents were confident about exercising choice, and that they were provided with individualised care and support. Who did this inspection Colin Goldie Beechmount, page 4 of 27

1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Information about all care services is available on our website at www.careinspectorate.com. This care service was previously registered with the care commission and transferred its registration to the care inspectorate on to 1 April 2011. Requirements and Recommendations If we are concerned about some aspect of a service, or think it could do more to improve its service, we may make a recommendation or requirement. - A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service but where failure to do so will not directly result in enforcement. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reforms (Scotland) Act 2010 and Regulations or Orders made under the Act, or a condition of registration. Where there are breaches of the Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Inspectorate. Beechmount Care Home provides care and support to a maximum of eight adults with learning disabilities. The home is a detached property set in its own grounds. Bedrooms are located on two levels and are all single occupancy. Only one bedroom has en suite facilities, the others have a wash-hand basin. There are two shared bathrooms, a sitting room and dining kitchen. The home is located in a residential area of Johnstone and is close to local amenities and transport. The organisation's principle states, "The primary aim of all of our services is to provide high quality support to individuals in a manner that enables them to live as fully as any other member of the community, and gain the benefits and responsibilities of citizenship." Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 5 - Very Good Quality of Environment - Grade 5 - Very Good Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 5 - Very Good Beechmount, page 5 of 27

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.careinspectorate.com or by calling us on 0845 600 9527 or visiting one of our offices. Beechmount, page 6 of 27

2 How we inspected this service The level of inspection we carried out In this service we carried out a low intensity inspection. We carry out these inspections when we are satisfied that services are working hard to provide consistently high standards of care. What we did during the inspection This report was written by Colin Goldie (Inspector) following an unannounced inspection between 14 and 20. May 2013. Feedback was given to the management team on the latter date. During this inspection information was gathered from a number of sources including: We spoke at length with: The manager, deputy manager, 8 support workers, residents and relatives. We looked at: Four support files. Review minutes. Risk assessments. Staff files. Staff supervision and appraisal records. Quality Assurance Questionnaires. Quality Assurance audit. Annual service review. Staff meeting minutes. Relative meeting minutes. Key Worker meeting minutes. Accident /incident records. Vehicle check list. Maintenance records. Daily record of fridge temperatures. Medication Storage. Medication administration records. Complaint log. Five returned Staff Questionnaires. Ten returned client/family Care Standard Questionnaires. Registration Certificate. Beechmount, page 7 of 27

Walk round of the care home. All of the above information was taken into account during the inspection process and reported on. 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 Beechmount, page 8 of 27

What the service has done to meet any recommendations we made at our last inspection There was one recommendation arising from the previous inspection: 1. Support plans should contain relevant information, be consistent and up to date. National Care Home for People with Learning Disabilities, Standard:6, Support arrangements and Standard 15, Keeping well- medication. When we read support plans we found that they were presented in a standard format, contained a wide range of information and were appropriately and accountably signed and dated. We saw evidence that care files are audited and any omissions noted and actioned. We were informed, and saw pilot examples, that the layout of care files has been reviewed and the format was being introduced in a phased manner. This recommendation is met. 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. The care inspectorate received a fully completed self assessment document from the provider. We were satisfied with the way the provider completed this and with the relevant information included for each heading that we grade services under. The provider identified what it thought the service did well, some areas for development and any changes it had planned. Beechmount, page 9 of 27

Taking the views of people using the care service into account Ten Care Standard Questionnaires had been returned by clients and relatives. Given many client's support needs these had been completed by relatives: "My parents are involved in choosing staff on my behalf." "(Named relative) will often go to her room to sit on her couch and relax." "Staff will often talk to (Named relative) in private and on a level she will understand." "(Named relative) and I came to look round and choose her room." "(Named relative) contributes to how the service is run art service user meetings." During the inspection we had the opportunity to speak with residents and observe staff interactions. People said and indicated that they were happy with the support being provided. Staff interactions were seen to be respectful and appropriate. Inspection report continued Taking carers' views into account Please see above. Beechmount, page 10 of 27

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: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths At this inspection we found that the performance of the service was very good for this statement. The service consulted and encouraged participation on a day to day basis very effectively. We observed staff practice, spoke with the manager, staff, residents and a relative. We looked at support files, review records and the service's satisfaction questionnaires and audit/action plan from returned questionnaires. The manager and staff said that Beechmount could only develop if they listen and, when possible, act on residents' views and suggestions. The service uses a range of ways to obtain people's opinions, for example: by having resident and relative meetings, using satisfaction questionnaires and regular 1:1 meetings between the client and their key worker. Questionnaires were issued and collated for the annual service review. The questionnaire asked for feedback about being involved, staff support, meals, safety, health care, the environment and activities. We saw that there are monthly resident meetings and quarterly relative forums. When we read meeting minuted we saw that a range of matters were discussed such as the previous meetings minutes, activities, Care Inspectorate questionnaires, menus and holidays. Residents spoken with were positive about the service saying that staff were approachable and that they were always asked for their opinions and ideas. One example of this was when a resident asked for their activity to be changed, we saw that this was accommodated. Beechmount, page 11 of 27

By reading support files we saw that resident were involved in decisions about their support and activities, for example going on holiday or day trips. Beechmount uses the key worker system. The key worker keeps in touch with families, makes sure support files are up to date and supports residents to get the most from their day. Key workers will help people complete Care Inspectorate questionnaires. Those returned indicated that residents, and relatives, were happy with the service provided. Residents are fully involved in developing their support file and deciding what they would like to do. We read four support files and saw that residents are supported to be involved in the community and take part in a range of activities such as going out for a walk, trips out and holidays. By encouraging residents to be involved in organising their support staff are reminded that the service is geared round the needs of the resident not the care home. There were regular team meetings. When we read minutes they showed that a range of matters were discussed, such as client support needs, training opportunities and service developments. Residents and relatives said that they knew about the service's complaints procedure and that they would use it if needed. The service had received one complaint since the last inspection. This remained under investigation during the inspection. Areas for improvement To continue to build on very good practice and consider how people can be further involved in developing the service. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Beechmount, page 12 of 27

Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Inspection report continued At this inspection we found that the performance of the service was very good for this statement. The service supported resident's health and well being very effectively. We spoke with residents, staff and a relative. We looked at support files, care plans, risk assessments, medication storage, medication records and review minutes. Staff spoke with respect and consideration of residents, acknowledging their individuality. Voyage Care has a range of policies and procedures addressing residents' health needs. These include medication, food hygiene, infection control, whistle blowing and protection of vulnerable adults. When talking to staff we found that they had a good knowledge of these and could explain how they worked. We saw evidence of this by reading review minutes. During the inspection we read four support files, health action plans and care plans. We saw that they were clearly written and easy to follow. By reading support files and talking with staff we saw that staff were experienced in supporting residents social, health and personal care needs. Care plans and discussion with residents showed that staff worked to support, maintain and improve individual's health. Staff do this by supporting people to keep active and be involved in the community. Plans showed that support is reviewed and updated to meet resident's developing health needs. Care files and health action plans were seen to contain a range of information including family contact details, risk assessments, client preferences and the service to be provided. Health needs are well documented. Plans show that health issue noted by staff are referred to the appropriate agency. We found that there were good relationships between the service and health and social care professionals, such as McMillan nurses, occupational therapist, dentist, optician, chiropodist, district nurse, dietician, Learning Disability Team and GPs. Any advice is clearly recorded and a Risk Assessment written when necessary. Risk Assessments note what staff must do to keep people safe and well, such as monitoring nutritional intake, weights, epileptic seizures and behaviour. Plans show that staff are very aware of and sensitive to residents' needs. Staff are provided with a range of training, including palliative care, epilepsy, challenging behaviour, adult protection, first aid and safe handling. Beechmount, page 13 of 27

When we looked at medication storage and administration records we saw that medication was securely stored and appropriately recorded. The manager was in the process of buying a controlled drug box. We had the opportunity to observe residents having meal, this was seen to be a relaxed and social occasion. There were notice boards around the home to inform residents and visitors of the staff on duty, the weekly menu and daily activities. Areas for improvement To continue to build on very good practice in this area. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Beechmount, page 14 of 27

Quality Theme 2: Quality of Environment Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths At this inspection we found that the performance of the service was very good for this statement. The service worked with residents and families effectively to improve the quality of environment. Please refer to Quality Theme 1, Statement 1 for further details. Areas for improvement Please refer to Quality Theme 1, Statement 1 for further details. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Beechmount, page 15 of 27

Statement 2 We make sure that the environment is safe and service users are protected. Service strengths At this inspection we found that the performance of the service was very good for this statement. We spoke with residents, staff and a relative. We looked round the care home and read the Maintenance Log, Accident/Incident records and individual risk assessments. The residents we spoke with during the inspection said that were happy living in Beechmount. Beechmount is a converted Victorian style mansion set in its own grounds. Bedrooms were seen to be personalised, clean and comfortably furnished. One has full ensuite facilities; the others have a wash-hand basin. We saw that residents were supported to choose the colour of their bedroom and to furnish it with their own possessions. We saw that staff were respectful of resident's confidentiality, individuality and privacy. They were seen to knock on bedroom doors and wait to be asked before entering. Care files note what staff must do to keep people safe and well, such as Risk Assessments and Personal Emergency Evacuation Plan. Beechmount has policies to make sure that the safety of the service is maintained, for example records are kept of daily and weekly checks. These included fire, medication, water temperatures and vehicle checks. The management also carried out monthly checks which included service reviews, accident and incident returns and an Operation Manager's report. An environment audit, which includes: all internal and external areas, flooring, furnishings, electrics and garden with areas for action highlighted was carried out every 2 months Accidents and incidents are recorded. Records showed that the manager carried out a monthly analysis of Accident and incidents. They were also reported to the organisation's Regional Office. Visitors are asked to sign in and out of the building. Areas for improvement Inspection report continued The organisation's environmental audit identified that Beechmount was in need of some refurbishment and decorating. During the inspection we saw that the hall Beechmount, page 16 of 27

carpet was stained, some wallpaper on ceilings did not match and a bed base was stained. We were told that Voyage Care was intending to address these matters in 2013. This will be noted as a recommendation. We noted that there were some notices on display that contained information about residents. This appropriateness of this was discussed with the management team with regards to residents confidentiality and dignity. This will be noted within a recommendation. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 2 Recommendations Inspection report continued 1. All planned refurbishment and painting work should occur before the end of 2013. This is to comply with national care standards: care homes for people with learning disabilities - Standard 4.8 "You can expect that the rooms and corridors are kept in good decorative order, and that the home and furnishings are well maintained and only essential notices are displayed." 2. Consideration should be given to displayed resident information - this must take account of confidentiality, dignity and privacy. This is to comply with national care standards: care homes for people with learning disabilities - Standard 4.8 "You can expect that the rooms and corridors are kept in good decorative order, and that the home and furnishings are well maintained and only essential notices are displayed." Beechmount, page 17 of 27

Quality Theme 3: Quality of Staffing Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths Relatives had been involved when new staff were being interviewed, using questions which reflected areas of importance to residents, for example, the characteristics of people who the resident would get on with and how staff would deal with certain behaviours or situations. Residents were given the opportunity to meet those interviewed during the recruitment process. Please refer to Quality Theme 1, Statement 1 for further details. Areas for improvement Please refer to Quality Theme 1, Statement 1 for further details. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Beechmount, page 18 of 27

Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths Inspection report continued At this inspection we found that the performance of the service was very good for this statement. Beechmount works to make sure that staff are professional, trained and motivated. We read staff files, training records, training plan, and supervision notes. We spoke with residents, a relative and staff. We observed staff practice. Staff spoke with respect and consideration of people living in Beechmount. We found that there was a consistent and experienced staff team. Staff had worked in Beechmount for a number of years, some since the care home opened. We found this had provided them with a range of experiences and sound knowledge base. The outcome of this was that residents had the advantage of being supported by staff who know them well and could spot any small changes that could have an impact on their health and wellbeing. Staff demonstrated a very good understanding of National Care Standards, showing a strong commitment to promoting residents independence. When first employed staff have induction training. This informs them of the service's expectations and their role in promoting and maintaining resident's dignity, independence and wellbeing. This training covers topics such as; policies and procedures, support planning, risk assessment, fire safety, and protecting vulnerable adults. The service had a mandatory training plan which provided staff with a range of learning opportunities such as induction, palliative care, dignity in care, visual awareness workshop, medication awareness, adult support and protection and Scottish Vocational Qualification in Social Care. Staff can access further training and the organisations policies and procedures on the company's e-learning system. Training is reviewed and updated through staff meetings and supervision to reflect residents support needs. When we spoke to staff we were told that the services had started to encourage people to become a "champion" for a specific area such dignity. It was their responsibility to identify best practice and inform other staff of this information. To make sure that staff continue to maintain good practice they have regular supervision and appraisal sessions. We looked at a number of supervision records. These showed that a range of areas were discussed such as client support needs, service developments and staff practice. Beechmount, page 19 of 27

Staff confirmed that supervision sessions take place monthly. By doing this the service can assure residents and families that any issues with staff practice are addressed and their work quality maintained. There are regular team meetings. When we read meeting minutes we saw that a range of matters are discussed such as people's support needs, planned activities, staff practice and service developments. Areas for improvement To continue to build on very good practice. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Beechmount, page 20 of 27

Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths At this inspection we found that the performance of the service was very good for this statement. The service worked with residents and relatives to assess and improve the quality of management. Please refer to Quality Theme 1, Statement 1 for further details. Areas for improvement Please refer to Quality Theme 1, Statement 1 for further details. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Beechmount, page 21 of 27

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 At this inspection we found that the performance of the service was very good for this statement. We talked to the management team, staff, residents and a relative. We looked at a range of quality assurance paperwork. We found that the service always ask residents and relatives for their views and opinions, using their comments to improve the service. The manager outlined how Voyage Care monitors and evaluates performance by having regular meeting with residents, using satisfaction questionnaires, meetings and monitoring visits by the external manager. The latter carry out regular service reviews of staff meetings, supervision and appraisal records, support plans and financial records. We saw that an action plan was developed to address any points of development. In addition to external audits the manager carries out regular check of medication records, support files and health plans. We saw that points of development were noted and remedial action put in place. The Manager submits annual returns, self evaluations, notification and action plans to the Care Inspectorate as expected. The service had received one complaint this year which was being investigated at the time of inspection. Areas for improvement As noted elsewhere in the report Voyage Care has a complaints policy. This noted that complaints or concerns should only be referred to the Care Inspectorate after they have been investigated by the company. This is not in line with the Care Inspectorate's "Procedure for handling complaints" which notes that the Care Inspectorate has a duty to investigate complaints whether or not the complainant has used the providers procedure. (The Public Services Reform (Scotland) Act 2010). This will be subject to a recommendation. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Beechmount, page 22 of 27

Recommendations Inspection report continued 1. The provider's complaint policy should note that complaints or concerns can be raised with the Care Inspectorate before, during or after making a complaint to the provider. The provider should supply a copy of the amended procedure to the Care Inspectorate within 3 months of the publication of this report. This is with reference to : Care Inspectorate - Procedure for handling complaints: Publication Code: COMP-1012-027. "The Care Inspectorate is governed by law (The Public Services Reform (Scotland) Act 2010). As such, we must have a procedure for receiving and investigating complaints, from members of the public or their representatives, about the care services they use. Our procedure must be available even when the service provider has a complaints procedure in place." "We will encourage complainants who wish to complain about a registered care service to try and resolve their complaint close to the source of their complaint where appropriate. For example, we will encourage the complainant to use the care service provider's complaints procedure. However, we will advise them that they can ask us to investigate from the outset or if they are not satisfied with the provider's investigation." "Our policy is to encourage complainants to raise matters of concern in the first instance with the provider. However, if the complainant wishes the Care Inspectorate to investigate the matter and it falls with our remit we will investigate." Beechmount, page 23 of 27

4 Other information Complaints One complaint was under investigation at the time of the inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information Five Care Standard Questionnaires had been returned by staff and seven staff were spoken with during the inspection. While staff were in the main positive about Beechmount there was a degree of confusion regarding individuals right to complain to the Care Inspectorate without going through the providers procedure in the first instance. This is noted as a reco 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 the Care Inspectorate re-grading a Quality Statement within the Quality of Management and Leadership Theme (or for childminders, Quality of Staffing Theme) as unsatisfactory (1). This will result in the Quality Theme being re-graded as unsatisfactory (1). Beechmount, page 24 of 27

5 Summary of grades Quality of Care and Support - 5 - Very Good Statement 1 Statement 3 5 - Very Good 5 - Very Good Quality of Environment - 5 - Very Good Statement 1 Statement 2 5 - Very Good 5 - Very Good Quality of Staffing - 5 - Very Good Statement 1 Statement 3 5 - Very Good 5 - Very Good Quality of Management and Leadership - 5 - Very Good Statement 1 Statement 4 5 - Very Good 5 - Very Good 6 Inspection and grading history Date Type Gradings 14 Jun 2012 Unannounced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good 14 Dec 2010 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed 13 Apr 2010 Announced Care and support 5 - Very Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed Beechmount, page 25 of 27

10 Dec 2009 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing 4 - Good Management and Leadership Not Assessed 23 Jun 2009 Announced Care and support 5 - Very Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 22 Jan 2009 Unannounced Care and support 3 - Adequate Environment 3 - Adequate Staffing 4 - Good Management and Leadership 4 - Good 3 Jun 2008 Announced Care and support 3 - Adequate Environment 3 - Adequate Staffing 4 - Good Management and Leadership 4 - Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Beechmount, page 26 of 27

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 the Care Inspectorate. You can get more copies of this report and others by downloading it from our website: www.careinspectorate.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@careinspectorate.com Web: www.careinspectorate.com Beechmount, page 27 of 27