Dunbeth Lodge Ltd Care Home Service Adults 98 Dunbeth Road Coatbridge ML5 3ES Inspected by: Ann Marie Hawthorne Ann Marie Palmer Type of inspection: Unannounced Inspection completed on: 11 February 2013
Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 16 4 Other information 26 5 Summary of grades 27 6 Inspection and grading history 27 Service provided by: Dunbeth Lodge LTD Service provider number: SP2009010662 Care service number: CS2009235208 Contact details for the inspector who inspected this service: Ann Marie Hawthorne Telephone 01698 897800 Email enquiries@careinspectorate.com Dunbeth Lodge Ltd, page 2 of 29
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 2 Weak Quality of Environment 2 Weak Quality of Staffing 2 Weak Quality of Management and Leadership 2 Weak What the service does well This is a small homely environment where residents appear comfortable. What the service could do better This service continues to improve the way in which information gathered about the needs of the residents is used to inform the care and support they receive. Personal plans and risk assessments need to be developed to reflect assessed need.they should include detailed support plans to meet these needs. The service would benefit from following the quality assurance system that they recently developed, for example, daily environmental checks, audit of personal plans, review of risk assessments. What the service has done since the last inspection A refurbishment plan had started in the service. The manager/provider was working to improve the standard of the accommodation. The entrance hall had been freshly decorated, lighting had been improved in the lounge area and display boards had been tidied up and held more clear up to date information. Progress had been made with professional registration. The manager and the supervisors had evidence that they had registered with the Scottish Social Services Council. Dunbeth Lodge Ltd, page 3 of 29
The service had started work to develop the personal plans and to carry out reviews with residents and their families. The staff team were improving the way in which they consult with people in relation to all aspects of the service. Conclusion II was apparent that the Provider / Manager of this service and her team were working to improve this service and that they remained very caring toward the people who lived in Dunbeth Lodge. There has been some progress made in some aspects of the service since the last inspection, however, there continues to be areas of the service that need to improve, for example, personal plans, risk assessments, staff training and supervision. There was evidence that the service have developed a quality assurance system but this had not been fully implemented at the time of this inspection. Who did this inspection Ann Marie Hawthorne Ann Marie Palmer Dunbeth Lodge Ltd, page 4 of 29
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 service was previously registered with the Care Commission and transferred its registration to the care Inspectorate on 1 April 2011. Requirements and recommendations If we are concerned about some aspect of a service, or think it could do more to improve, 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. Recommendations are based on the National Care Standards, relevant codes of practice and recognised good practice. A requirement is a statement, which sets out what is required of a care service to comply with the Public Services Reform (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 Care Inspectorate. Dunbeth Lodge is a small, privately owned care Home in Coatbridge which was registered with the current provider in March 2011. It is registered to provide residential care to a maximum of 18 older people with a variety of care needs. At the time of the inspection there were 10 people resident in the home. The home also provides short stay accommodation for people who require respite care. There were no residents using the home for a short break at the time of this inspection. The home consists of 14 single and 2 double bedrooms. There is a range of communal space available as well as a secure garden area. The service is situated in a quiet residential area of Coatbridge and is accessible to local facilities and public transport links. The aims and objectives for this service were ''to provide a personal service in a friendly, caring and safe environment''. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 2 - Weak Quality of Environment - Grade 2 - Weak Quality of Staffing - Grade 2 - Weak Quality of Management and Leadership - Grade 2 - Weak Dunbeth Lodge Ltd, page 5 of 29
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. Dunbeth Lodge Ltd, page 6 of 29
2 How we inspected this service The level of inspection we carried out In this service we carried out a high intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection We wrote this report following an unannounced inspection. This was carried out by Ann Marie Hawthorne, Inspector and Annmarie Palmer, Inspector. The inspection took place on Monday 11th February 2013 between 9.30am and 6.40pm. As part of the inspection, we took account of the annual return and self - assessment forms that we asked the provider to complete and submit to us. We sent care standards questionnaires to the manager to distribute to people who use this service, we received no completed questionnaires. We also asked the manager to give out care standard questionnaires to relatives and carers of people who use this service, we received three completed questionnaires. During this inspection process we gathered evidence from various sources, including the following; Speaking with and observing the residents engaging in activities Speaking to the Manager and Supervisor Observation of the environment Reading information in Care Standard Questionnaires returned to us Review of the service action plan from the last Care Inspection report Review of Personal Plans Maintenance records Staff rotas Residency Agreements Supervision records Training certificates Policies and procedures Medication records Review of menus Dunbeth Lodge Ltd, page 7 of 29
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 report continued 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 Dunbeth Lodge Ltd, page 8 of 29
What the service has done to meet any requirements we made at our last inspection The requirement The service must ensure that the residents personal plan fully reflects how their health care needs will be addressed and clearly reflects the support needed from staff to ensure that this is carried out. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) regulation 5(1) - a requirement that a provider shall, after consultation with each service user and, where it appears to the provider to be appropriate, any representative, within one month of the date on which the service user first received the service prepare a written plan which sets out how the service user's health and welfare needs are to be met. Timescale for implementation: 2 months from receipt of this report. What the service did to meet the requirement Some work had started to develop the personal plans but this was incomplete. The staff team continue to work on this requirement. This requirement has been repeated. The requirement is: Not Met Dunbeth Lodge Ltd, page 9 of 29
The requirement The provider must ensure that residents and their families/carers are involved in formally reviewing the personal plans within each six month period. In order to do this the provider must develop a plan for reviews and invite appropriate people to attend. This is to comply with SSI2011/210; Personal plans Regulation 5 (2) A provider of a care service must (b) review the personal plan ( i) when requested to do so by the service user or any representative;(ii) when there is a significant change in a service user's health, welfare or safety needs; and (iii) at least once in every six month period whilst the service user is in receipt of the service; (c) where appropriate, after any review mentioned in sub-paragraph (b), and after consultation with the service user and, where it appears to the provider to be appropriate, any representative, revise the personal plan; and (d) notify the service user and any representative consulted under paragraph (2)(c) of any such revision. Timescale: Within 1Month of receipt of this report. What the service did to meet the requirement The manager/provider informed us that some but not all residents had reviews carried out and that they continued to plan reviews to ensure all residents have a review carried out and a forward plan made for subsequent reviews. This is requirement has been repeated. The requirement is: Not Met Inspection report continued The requirement The Provider must ensure that the resident's personal plan contains detail of actions which need to be taken to meet assessed health care needs. This is to comply with SSI 2011/210; 5(1) - a requirement that a provider shall, after consultation with each service user and, where it appears to the provider to be appropriate, any representative, within one month of the date on which the service user first received the service prepare a written plan which sets out how the service user's health and welfare needs are to be met. Timescale: Within 2 months from receipt of this report (This is a repeat requirement). What the service did to meet the requirement The team have made some progress with this requirement, we will review further progress at the next inspection. The requirement is: Not Met The requirement The provider must ensure that all staff, including the Manager receive training appropriate to their roles and responsibilities in order to understand and effectively Dunbeth Lodge Ltd, page 10 of 29
care for each service user where applicable in terms of the Adults with Incapacity (Scotland) Act 2000 and the Mental Health Care and Treatment (Scotland) Act (2003). Where appropriate, Certificates of Incapacity should be sought. The Provider must ensure that the outcome of this training is that best practice in relation to legislation is reflected in the Personal Plans. This is to comply with SSI 2011/210; 4(1) A provider must - (a) make proper provision for the health, welfare and safety of service users; (b) provide services in a manner which respects the privacy and dignity of service users; (c) ensure that no service user is subject to restraint, unless it is the only practicable means of securing the welfare and safety of that or any other service user and there are exceptional circumstances. Timescale: within 2 months of receipt of this report. What the service did to meet the requirement The service have identified and plan to attend this training in the near future. The requirement is: Not Met Inspection report continued The requirement The provider must review the way in which the staff complete Incident forms and demonstrate in writing that any hazards are reviewed and action taken where necessary to reduce the potential for harm. The provider must also ensure that a review the staff knowledge and skills in the application of first aid is carried out and take steps to address any deficits in knowledge through training. This is to comply with SSI 2011/210; 4(1) A provider must - (a) make proper provision for the health, welfare and safety of service users; (b) provide services in a manner which respects the privacy and dignity of service users; (c) ensure that no service user is subject to restraint, unless it is the only practicable means of securing the welfare and safety of that or any other service user and there are exceptional circumstances. Timescale: within 1 month of receipt of this report. What the service did to meet the requirement The service have carried out training with the staff team in relation to the completion of incident forms. They have not yet identified training in responding to first aid. The requirement is: Met The requirement The Provider must review all outstanding reports relating to environmental safety and ensure that action is taken to address issues identified. This must include the repair or replacement of the hoist in the main bathroom and a deep clean of all areas. This is to comply with SSI 210 10 (2) Premises are not fit to be used for the provision of a care service unless they - (b) are of sound construction and kept in a good state of repair externally and internally (c) have adequate and suitable ventilation, heating and Dunbeth Lodge Ltd, page 11 of 29
lighting, and (d) are decorated and maintained to a standard appropriate for the care service. Timescale: Within 1 month of receipt of this report. What the service did to meet the requirement A new hoist seat was purchased, we saw evidence of receipt. The home did appear to be cleaner and a deep clean schedule has been established. The requirement is: Met Inspection report continued The requirement The Provider must review the documentation relating to accidents and incidents within the home and ensure that all staff know how to complete the forms and are aware of the importance of doing this. The provider must also undertake a written analysis of the nature of the incidents / accidents to ensure that action can be taken to reduce potential for any repeat incident. This is to comply with SSI 210 4 (1) (a) make proper provision for the health, welfare and safety of service users. Timescale: Within 4 weeks of receipt of this report. What the service did to meet the requirement The service have reviewed the documentation used to record incident reports. there had been no incidents recorded since the last inspection, we will follow this up at future inspections. The requirement is: Met The requirement The Provider must introduce a risk assessment for the use of the smoke room. This must consider the smoking habits of the individual and must reflect that individual support / observation has been considered for individuals while smoking. The risk assessment must also reflect steps including frequent safety checks of the smoke room, frequent emptying of the ashtrays and a nightly check of the smoke room incorporating all of the above. These checks must be recorded signed and timed. This is to comply with SSI 210 4 (1) (a) make proper provision for the health, welfare and safety of service users. Timescale: Within 4 weeks of receipt of this report. What the service did to meet the requirement A review of the risk assessment had been carried out, hourly checks were in meant to take place but had not been recorded. In addition, we observed that one individual was using the smoke area and was not monitored during this time. There are known risks involved for this individual and observation is essential. The requirement is: Not Met Dunbeth Lodge Ltd, page 12 of 29
The requirement The provider must ensure that the Manager and Supervisor apply for and evidence that they have applied for registration with the Scottish Social Services Council. This is to comply with SSI 210 15 (a) ensure that at all times suitably qualified and competent persons are working in the care service in such numbers as are appropriate for the health, welfare and safety of service users. Timescale: Within one month of receipt of this report What the service did to meet the requirement The Manager and Supervisors have now registered with the Scottish Social Services Council. The requirement is: Met Inspection report continued Dunbeth Lodge Ltd, page 13 of 29
The requirement The/Provider must ensure that the staffing levels comply with those stated in the staffing schedule at all times This is to comply with SSI 210 15 (a) ensure that at all times suitably qualified and competent persons are working in the care service in such numbers as are appropriate for the health, welfare and safety of service users. Timescale Within 24 hours of receipt of this report Requirement 11 The / Provider must ensure that it carried out safe recruitment of staff including; Ensuring all applicants complete an application Prospective applicants are interviewed appropriately Two references, one from a previous employer, are sought and deemed to be acceptable PVG checks are undertaken for all staff prior to employment and, where a conviction is noted and the individual is employed, the provider must demonstrate how they reached this decision.the service must advise the Care Inspectorate in writing of the action they are taking to address the recruitment issue raised at inspection.this is to comply with SSI 9 Fitness of employee: A provider must not employ any person in the provision of a care service unless that person is fit to be so employed. Timescale: Within one week of receipt of this report Requirement 12 The Manager/Provider must develop a quality assurance system which reviews key aspects of service delivery including but not limited to care plans, environment, medication, incidents and accidents. The quality assurance system must also reflect the views of families/representatives and staff. This is to comply with SSI 210 4 - (1) A provider must - (a) make proper provision for the health, welfare and safety of service users. What the service did to meet the requirement On review of the duty rota which was provided to us there was evidence that the service is failing to ensure that senior staff are on duty at all times or that the numbers of staff on duty at all times is compliant with the staffing schedule. The requirement is: Not Met Inspection report continued What the service has done to meet any recommendations we made at our last inspection Actions taken on Requirement 11 Some action has been taken to meet this requirement however recruitment from the date of the previous inspection has not been robust and needs a more robust approach. Not Met Dunbeth Lodge Ltd, page 14 of 29
Actions taken on Requirement 12 A quality assurance system has been developed but is not yet in use. Not Met Inspection report continued 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 service provided us with a self assessment at the start of the inspection year, the information provided was limited. Taking the views of people using the care service into account We spoke to people who use the service throughout the duration of the inspection. They told us they like living in Dunbeth Lodge. They told us they can make choices about what they do. The people we spoke to said the staff treat them well. One lady said "I like it here, everybody is nice", another told us "its a nice wee place, they come and ask if you need help, you don't have to wait". Taking carers' views into account Three family members returned completed care standards questionnaires to us.these were all completed very positively, Some comments include 'the service is very homely and person centred". The respondents strongly agreed that the staff know their relatives likes and dislikes. Dunbeth Lodge Ltd, page 15 of 29
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: 2 - Weak 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 We have considered this statement in relation to all quality themes and have incorporated our findings in participation across environment, staffing and leadership/management in this statement. We found that the service had made some improvement in this area since the previous inspection. There were improvements noted in the way that information was displayed, for example the complaints policy, advocacy information and information about activities that were available for residents each day. The service continued to consider ways in which they could obtain the views of the residents and relatives to assess and improve the quality of care. We saw an example of this in that residents influence the menu within the home, the service had started to gather feedback from people in relation to their likes and dislikes in relation to food choices and the menu is adjusted to reflect this. The atmosphere within the home is calm and relaxed and people were observed to behave in a way that suggests that they can use the home in the way that they choose, for example people can choose to sit in their bedroom or any of the lounges. We saw that people can choose to have drinks or snacks throughout the day as they wish. We considered the views of the carers who returned care standard questionnaires in this quality statement. All three respondents told us that they agree strongly that their relative/friend is able to feedback their views about the quality of the service, and the management of the service takes these seriously. Dunbeth Lodge Ltd, page 16 of 29
Areas for improvement The manager told us that some reviews had taken place and that others were planned, however, there was a lack of evidence that reviews were planned and taking place within each six month period as required in legislation (See requirement 1). The manager / provider remains unable to demonstrate how they seek the views of people who have cognitive impairment (see recommendation 1). The manager/provider told us in the action plan submitted in November 2012 that they planned to review the complaints procedure, they have not done this. We will look at progress with this at the next inspection. The service should continue to develop the way in which they provide opportunities for meaningful activity for residents. The should review the way in which they involve residents in deciding what they would like to do and take account of information included in life history documents held within the file for the individual. They have started to develop this and now display a range of activities that will take place each day, however we identified choices and preferences in discussion with residents that were not reflected in their personal plans or in the activities offered. The service should continue to create opportunity for residents to provide their views on the service they receive, we will look at the ongoing progress of this at the next inspection. Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 1 Requirements Inspection report continued 1. The provider must ensure that residents and their families/carers are involved in formally reviewing the personal plans within each six month period. This is to comply with SSI2011/210; Personal plans Regulation 5 (2) A provider of a care service must (b) review the personal plan ( i) when requested to do so by the service user or any representative;(ii) when there is a significant change in a service user's health, welfare or safety needs; and (iii) at least once in every six month period whilst the service user is in receipt of the service; (c) where appropriate, after any review mentioned in sub-paragraph (b), and after consultation with the service user and, where it appears to the provider to be appropriate, any representative, revise the personal plan; and (d) notify the service user and any representative consulted under paragraph (2)(c) of any such revision. Timescale: Within 2 Months of receipt of this report. This is a repeat requirement. Dunbeth Lodge Ltd, page 17 of 29
Recommendations 1. The service should ensure that methods used to engage residents in improving the quality of care and support are inclusive and accessible to all residents particularly those with cognitive impairment such as dementia. National Care Standard 18: Staying in touch Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths The service is working through the requirements and the recommendations made in the previous report and we recognise that some aspects of this quality theme have started to improve. We saw that the people who who were resident in this home continued to appear well and look cared for. People told us in care standard questionnaires that their relatives experienced "person centred care" and that the care and support provided to their relatives "could not be better". The people we spoke to throughout the period of inspection told us they liked living in Dunbeth Lodge and that they were "well looked after". We saw some evidence that the staff seek the support of external health agencies, for example, dietician or district nurses when required. We saw that the staff know the residents well and that they respond to the needs and wishes of the residents in a reactive and kind way. Work has started to review and improve the personal plans and the support plans within these. Training has taken place to help staff to understand the way in which they should be completing incident and accident reports, this is to ensure that all important information about incidents which effect the health and wellbeing of people who use tis service are reported upon and appropriate action is taken. Areas for improvement Aspects of this quality statement were unmet in a way that gives cause for concern and therefore we have graded this statement as weak. We saw that for some people there continued to be a lack of detail in personal plans. This included the absence of support plans for people at risk of, for example, skin breakdown, stoma care, the absence of moving and handling support plans and risk assessments. There was no evidence that these needs were being met in a planned and systematic way. The continued absence of information to guide and monitor the effectiveness of care and support could have a negative impact on the health and welfare of the residents (See requirement 1). We looked at the legal status of the people living in this service and could see that some work was being done to review and clarify the position for people in relation to legislation and their rights, however, there continued to be areas which needed further development, for example, whee required,assessments of capacity and the section 47 form - statement of incapacity and treatment plans have not yet been completed by the GP practice. There continued to be a lack of understanding of the Dunbeth Lodge Ltd, page 18 of 29
importance of this among the staff group. Decisions were still being made for people without full consideration of their legal status. We made a requirement in the previous inspection report that the manager, supervisors and staff require to receive training to understand their responsibilities within the legal framework. We were informed that this training has been sourced and will take place. This requirement will be repeated (See requirement 2). Grade awarded for this statement: 2 - Weak Number of requirements: 2 Number of recommendations: 0 Requirements Inspection report continued 1. The Provider must ensure that the resident's personal plan contains detail of actions which need to be taken to meet assessed health care needs. This is to comply with SSI 2011/210; 5(1) - a requirement that a provider shall, after consultation with each service user and, where it appears to the provider to be appropriate, any representative, within one month of the date on which the service user first received the service prepare a written plan which sets out how the service user's health and welfare needs are to be met. Timescale: Within 6 weeks from receipt of this report This is a repeat requirement. 2. All staff, including the Manager, must receive training appropriate to their roles and responsibilities in order to understand and effectively care for each service user where applicable in terms of the Adults with Incapacity (Scotland) Act 2000 and the Mental Health Care and Treatment (Scotland) Act (2003) The Provider must ensure that the outcome of this training is that best practice in relation to legislation is reflected in the Personal Plans. This is to comply with SSI 2011/210; 4(1) A provider must - (a) make proper provision for the health, welfare and safety of service users; (b) provide services in a manner which respects the privacy and dignity of service users; (c) ensure that no service user is subject to restraint, unless it is the only practicable means of securing the welfare and safety of that or any other service user and there are exceptional circumstances. Timescale: within 6 weeks of receipt of this report. This is a repeat requirement Dunbeth Lodge Ltd, page 19 of 29
Quality Theme 2: Quality of Environment Grade awarded for this theme: 2 - Weak Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths We have considered this quality theme in the narrative and grades awarded under quality theme 1, statement 1. Areas for improvement see quality theme 1, statement 1. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths There was evidence that the service had improved in some aspects covered by this quality theme since the previous inspection. The entrance to the home was brighter and had been freshly decorated. The home and all carpets had been deep cleaned in the weeks prior to the inspection. A plan has been introduced to steam clean the carpets every three months. Some radiators had been replaced. The broken seat on the hoist in the bathroom had been replaced. Areas for improvement There were some areas of the home which were beginning to show signs that the standard of cleanliness had not been maintained since the deep clean was carried out. There was no evidence of daily cleaning schedules in the kitchen, some areas including the sinks, fridge and cutlery holders needed to be cleaned. We saw that the dishwasher in the main kitchen area was broken and that the dishes were being washed by hand ( Requirement 1).The maintenance logs had not been completed since before the previous inspection. Dunbeth Lodge Ltd, page 20 of 29
A risk assessment had been carried out in the smoke room and supporting documentation was in place to record evidence that hourly checks would be carried out to empty ash trays and check for any hazards. In addition, this would incorporate risk assessments for individuals who use the smoke room. However, we checked the documentation and the hourly checks had not been getting recorded. We saw that one resident often leaves the designated smoke area with a lit cigarette, we saw burn marks consistent with cigarettes being balanced on the edge of the bath in the bathroom closest to the smoke room. The risk assessment for this person states that they should be observed until the cigarette is extinguished. We saw the person smoking unobserved throughout the day of the inspection (requirement 2). Grade awarded for this statement: 2 - Weak Number of requirements: 2 Number of recommendations: 0 Requirements Inspection report continued 1. The Provider must review all outstanding reports relating to environmental safety and ensure that action is taken to address issues identified. This must include the repair or replacement of the dishwasher in the kitchen. The provider must take steps to ensure that daily cleaning schedules are maintained, and that maintenance logs are brought up to date and maintained.this is to comply with SS! 210 10 (2)Premises are not fit to be used for the provision of a care service unless they - (b) are of sound construction and kept in a good state of repair externally and internally (c) have adequate and suitable ventilation, heating and lighting, and (d) are decorated and maintained to a standard appropriate for the care service. Timescale: Within 1 month of receipt of this report. 2. The Provider must introduce a risk assessment for the use of the smoke room. This must consider the smoking habits of the individual and must reflect that individual support / observation has been considered for individuals while smoking. The risk assessment must also reflect steps including frequent safety checks of the smoke room, frequent emptying of the ashtrays and a nightly check of the smoke room incorporating all of the above. These checks must be recorded signed and timed. This is to comply with SSI 210 4 (1) (a) make proper provision for the health, welfare and safety of service users. Timescale: Within 24 hours of receipt of this report. this is a repeat requirement. Dunbeth Lodge Ltd, page 21 of 29
Quality Theme 3: Quality of Staffing Grade awarded for this theme: 2 - Weak Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths We have considered this quality theme in the narrative and grades awarded under quality theme 1, statement 1. Areas for improvement quality theme 1, statement 1. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths The service have improved in this area since the previous inspection in that the manager has now registered with the Scottish Social Services Council. Both supervisors have now applied to register, as required by law, with the Scottish Social Services Council. In addition to this, the service had started to provide a programme of training for staff. One group of staff were receiving training in moving and handling while the inspection was taking place. Some staff had received training in falls management. We met with the trainer for the service and reviewed the certificates of accreditation that they held. Workbooks have been introduced on Adult Support and Protection and Health and safety. These will be issued to all staff. Areas for improvement The service needs to develop an overall training needs analysis in order that they can plan regular training for staff. They are considering how they will monitor the Dunbeth Lodge Ltd, page 22 of 29
competency of the staff as they complete the workbooks and we will look at the outcome of this at the next inspection. We saw evidence of supervision taking place but the narrative did not indicate that there was discussion in relation to strengths or areas of development. We will look at this area at the next inspection. On review of the duty roster for the six weeks preceding this inspection it was evident that there are times when there are only two staff on duty when there should be a minimum of three. In addition to this there are times when there are no registered/ senior staff on duty (Requirement 1). We followed up on the requirement on recruitment that we Ade at the last inspection. We found that the service have not yet developed a robust approach to recruitment. We found that there was insufficient evidence of robust information in relation to interview records and references from previous employers, this requirement will be repeated (requirement 2) Grade awarded for this statement: 2 - Weak Number of requirements: 2 Number of recommendations: 0 Requirements Inspection report continued 1. The Manager/Provider must ensure that the staffing levels comply with those stated in the staffing schedule at all times This is to comply with SSI 210 15 (a) ensure that at all times suitably qualified and competent persons are working in the care service in such numbers as are appropriate for the health, welfare and safety of service users. Timescale: within 24 hours of receiving this report. This is a repeat requirement. 2. The Manager / Provider must ensure that it carried out safe recruitment of staff including; Ensuring all applicants complete an application Prospective applicants are interviewed appropriately Two references, one from a previous employer, are sought and deemed to be acceptable PVG checks are undertaken for all staff prior to employment.this is to comply with SSI 9 Fitness of employee: A provider must not employ any person in the provision of a care service unless that person is fit to be so employed. Timescale: Within one week of receipt of this report. this is a repeat requirement Dunbeth Lodge Ltd, page 23 of 29
Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 2 - Weak 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 We have considered this quality theme in the narrative and grades awarded under quality theme 1, statement 1 Areas for improvement see quality theme 1, statement 1 Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 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 service have now developed a range of audits which they plan to use to measure the quality of this service. Areas for improvement Audits have not yet been used effectively in practice. The environmental audits have been used but these have not been useful in highlighting issues that we identified in this inspection (requirement 1). The requirements made at the previous inspection will be repeated and we will look at the progress in this quality theme during the next inspection. Grade awarded for this statement: 2 - Weak Number of requirements: 1 Number of recommendations: 0 Dunbeth Lodge Ltd, page 24 of 29
Requirements Inspection report continued 1. The Manager/Provider must develop a quality assurance system which reviews key aspects of service delivery including but not limited to care plans, environment, medication, incidents and accidents. The quality assurance system must also reflect the views of families/representatives and staff. This is to comply with SSI 210 4 - (1) A provider must - (a) make proper provision for the health, welfare and safety of service users. Timescale: Within 4 weeks of receipt of this report This is a repeat requirement. Dunbeth Lodge Ltd, page 25 of 29
4 Other information Complaints No complaints have been upheld, or partially upheld, since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information This inspection focused on the areas discussed in the previous inspection report and on progress made with the requirements and recommendations set out in the action plan at that time. 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). Dunbeth Lodge Ltd, page 26 of 29
5 Summary of grades Quality of Care and Support - 2 - Weak Statement 1 Statement 3 3 - Adequate 2 - Weak Quality of Environment - 2 - Weak Statement 1 Statement 2 3 - Adequate 2 - Weak Quality of Staffing - 2 - Weak Statement 1 Statement 3 3 - Adequate 2 - Weak Quality of Management and Leadership - 2 - Weak Statement 1 Statement 4 3 - Adequate 2 - Weak 6 Inspection and grading history Date Type Gradings 18 Oct 2012 Unannounced Care and support 2 - Weak Environment 2 - Weak Staffing 1 - Unsatisfactory Management and Leadership 1 - Unsatisfactory 11 Jan 2012 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 3 - Adequate 27 Jun 2011 Unannounced Care and support 3 - Adequate Environment 3 - Adequate Staffing Not Assessed Management and Leadership Not Assessed Dunbeth Lodge Ltd, page 27 of 29
All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Dunbeth Lodge Ltd, page 28 of 29
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 Dunbeth Lodge Ltd, page 29 of 29