Care service inspection report

Transcription

1 Care service inspection report Full inspection Methven House Care Home Service 14 Bennochy Road Kirkcaldy Inspection completed on 06 June 2016

2 Service provided by: Kingdom Homes Ltd Service provider number: SP Care service number: CS Inspection Visit Type: Unannounced Care services in Scotland cannot operate unless they are registered with the Care Inspectorate. We inspect, award grades and set out improvements that must be made. We also investigate complaints about care services and take action when things aren't good enough. Please get in touch with us if you would like more information or have any concerns about a care service. Contact Us Care Inspectorate Compass House 11 Riverside Drive Dundee DD1 4NY enquiries@careinspectorate.com page 2 of 43

3 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 Quality of environment 3 Quality of staffing 2 Quality of management and leadership 2 Adequate Adequate Weak Weak What the service does well We received a few positive comments from residents and visiting relatives in relation to how the staff within the service work hard to support residents. What the service could do better We have repeated requirements in relation to personal plans/risk assessments, monitoring nutrition/hydration needs of residents and having effective quality assurance systems to promote quality and safety. We have made requirements in connection with improving recruitment procedures by having robust pre-employment checks, ensuring care staff are registered with the regulatory body SSSC, ensuring that the service is appropriately staffed including having the correct skill mix on shifts. We have made six recommendations which relate to improving staff practices, records, cleanliness and equipment. page 3 of 43

4 What the service has done since the last inspection Inspection report The service has met six of nine requirements made at the previous inspection. One requirement related specifically to a resident who no longer resides within the home, we therefore were unable to follow this up. The management team have involved staff in taking forward key areas of the service. Conclusion Based upon our findings we have graded themes 1 quality of care and support and theme 2 quality of environment as grades of 3 - adequate. Themes 3 quality of staff and theme 4 quality of management and leadership have been graded as 2 - weak. A follow up inspection will be carried out to check progress. page 4 of 43

5 1 About the service we inspected Inspection report Methven House is registered to provide 24-hour care for a maximum of 62 people. Methven House offers long-term residential care and nursing care for older people. Two named older adults are included in the numbers. The home is laid out on three levels, with all rooms being spacious, well fitted out, and all having en-suite facilities. The top floor of the home has larger bedrooms, which provide ample space for easy chairs or a small sofa. All bedrooms have a telephone and television point. On two of the three floors there is an internet café style room, with refreshments available and access to the internet if wished. Outside the home, there is ample car parking to the rear of the building. At the front of the home there is a large open garden space with shrubs and walkways. Raised flower beds also feature in this garden. The property is close to local amenities and accessible to Kirkcaldy town centre. The home is situated adjacent to the local railway station and within walking distance of the local bus station. Although the property faces a busy road, there are attractive views of the municipal gardens. The people who live in Methven House prefer to be known as residents, therefore this term has been used throughout this report. Recommendations A recommendation is a statement that sets out actions that a care service provider should take to improve or develop the quality of the service, but where failure to do so would not directly result in enforcement. Recommendations are based on the National Care Standards, SSSC codes of practice and recognised good practice. These must also be outcomes-based and if the provider meets the recommendation this would improve outcomes for people receiving the service. page 5 of 43

6 Requirements A requirement is a statement which sets out what a care service must do to improve outcomes for people who use services and must be linked to a breach in the Public Services Reform (Scotland) Act 2010 (the "Act"), its regulations, or orders made under the Act, or a condition of registration. Requirements are enforceable in law. We make requirements where (a) there is evidence of poor outcomes for people using the service or (b) there is the potential for poor outcomes which would affect people's health, safety or welfare. 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 2 - Weak Quality of management and leadership - Grade 2 - Weak Inspection report 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 or by calling us on or visiting one of our offices. page 6 of 43

7 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 An unannounced inspection was carried out by two inspectors on 5 June 2016 between the hours of 9.50am to 5.20pm and 9.40am to 5.30pm on 6 June Prior to the inspection we looked at the certificate of registration, staffing schedule, self assessment, electronic notifications, complaint investigated and annual return submitted by the service. During the inspection we carried out the following activities; - - Speaking with residents and observing staff practice and interactions with residents - Speaking with visiting relatives to hear their views on the service - Speaking with the registered manager, assistant manager, nursing, care staff and operations manager - Carrying out an environmental inspection of each floor - Examining a range of documents including seven care plans and associated assessments - Looking at records associated with health and safety and maintenance of the building - Checking records relating to the recruitment, registration, staffing and the support and development of staff - Examining the quality assurance systems used and looking at how these effect change within the service. Feedback was given on our findings and grades awarded to the registered manager, operations manager, assistant manager, team leader and link officer from Fife Council. page 7 of 43

8 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 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 page 8 of 43

9 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 service provider. We found that the self assessed grades provided by the service were significantly higher than those awarded as a result of the findings of the inspection. Taking the views of people using the care service into account Comments received; - "Overall, happy living here, if I'm unhappy I tell staff and I have spoken with the manager." "The food is a bit mixed. I find it depends on who is doing the cooking." "I think they use too many dairy products." "The food is nice". "Room is comfortable". page 9 of 43

10 Taking carers' views into account We received a number of positive comments in relation to the staff; - "The staff are very good - they work hard". "Staff are really good. The staff are lovely". We also received some positive comments about the environment; - "The care home is always clean and tidy when I visit." "The food is ok." We received a number of less positive comments in relation to the service; - "The staff often appear quite busy". "Although I'm confident in the manager who has introduced new systems, I've been told staffing is adequate but not convinced. I waited in a response from staff for half an hour." "There are times when there are no staff in the sitting rooms which can be concerning when residents are confused." "I find that there are poor communications between staff on shift, between management and staff and with us relatives. There is not much communication by the management team with families informing them how they plan to take areas of the service forward." "I don't see many activities or one to one time being carried out with residents when I visit." page 10 of 43

11 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 3 - Adequate Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Our examination of records, observations of practice, discussion with residents, relatives, staff and the manager supported that the service performs at an adequate level in this quality statement. We observed the meal time experience for residents and found that there had been some improvements in practice since the previous inspection. Staff supported those residents who required assistance to clean their hands in advance of eating. The service has introduced pictorial menus to help residents make an informed choice of what they would prefer to eat. Staff also gave residents information on the choices available with food and drinks. Based upon our observations we concluded that the requirement made in the previous inspection in connection with the dining experience has been met. We identify within areas of improvement further work required to make improvement in relation to meeting the nutrition and hydration needs of residents. page 11 of 43

12 We looked at records and spoke with staff in relation to the management, administration and recording of medications. Overall, we found that there had been improvement to this area; we found no hand written entries in our sample and found clearer information of follow up actions taken when medication errors are made. Based upon our findings we concluded that the requirement made in connection with this area has been met. However, we make comment in areas for improvement below to further improvements that should be made. We observed a group activity being carried out with residents on the second day of the inspection and noted residents engaged positively with discussions. In discussion with the management team we were informed that the service uses planned activity level (PAL) tool to inform the most appropriate group for residents to be directed to. Areas for improvement We looked at records used by staff to monitor individual residents who may be at risk of becoming dehydrated and malnourished. We can see that the management team have introduced a "ready reckoner" to help staff identify specific targets for each resident. However, we found that the charts were often incomplete and were not being used to shape associated care plans. We also identified inaccurate scoring of the MUST tool used to identify residents who may be at risk of becoming malnourished. We gave examples of individual residents who the above related to during the feedback session. Based upon our findings the associated requirement made at the previous inspection has not been met. This requirement also relates to quality theme 4, statement 4. See requirement 1. We identified that the "soft" diet option for residents who have eating swallowing difficulties was poorly presented. The service provider should also review availability of suitable soft diet options for residents outwith main meal times e.g. supper and also review the early dinner provision on a Sunday afternoon. We shall make a recommendation in relation to soft diet provision. See recommendation 1. page 12 of 43

13 We examined care plans and associated assessments which are used to inform staff how care and support should be delivered. We identified a number of improvements which must be made by the service provider. We found that the legal status of each resident was not reflected within files sampled. This is very important information as it reflects who has the authority to make decisions in relation to the health and wellbeing needs of each resident. Care plans did not reflect the current needs of individual residents and often were of a generic nature. We expect that care plans would be in place to guide staff on how to support residents who due to the nature of their condition may exhibit stress and distress reactions. We identified risk assessments which either had been inaccurately completed or had not identified suitable strategies for reducing potential risks to residents. This related to the assessment and use of bedrails. We shared examples on the above at feedback including examples in relation to choking risk assessments. We highlighted that records of review meetings were also missing from files and that there was not robust evaluation being carried out to care plans to check that they were up to date and reflective of current needs. We heard that the manager had initiated audits of care plans and how they intended to make improvements. Based upon our findings the requirement made in connection with this area at the previous inspection is not met and the above findings also relate to quality theme 4, statement 4. See requirement 2. A requirement was made in the previous inspection in relation to staff administering pain relieving medication on an "as required" basis for a specific individual who no longer resides within the home. We found that the staff within the service had initiated "just in case" medications for individual resident for use for the management of pain. However, we found that plan of care for residents who require pain relief on an as required basis to be very generic and not specific to meeting individual's needs. We shall make a recommendation in connection with this area. See recommendation 2. page 13 of 43

14 Whilst we identified overall improvement in relation to the management, administration and recording of medications given to residents we identified two entries which contained no staff signatures and meant that prescribed medications not being administered on these occasions. This is an area that we will monitor in future inspections. We looked at the appearances of some residents and found the need for stained clothes to be changed. We cross referenced with personal care records and noted that these were not fully completed or indicating that specific support had been carried out which were at odds with our findings. We shall make a recommendation that records are fully completed by staff and that there is close monitoring to ensure the personal care needs of each resident are being met. See recommendation 3. The service provider should continue to work on and continue to involve residents, relatives/carers and staff on developing the range of activities available and be mindful of the time spent with all residents with regard of each person's abilities. Grade 3 - Adequate Requirements Number of requirements The Provider must satisfy themselves that staff who complete observation charts such as daily fluid and food intake have the knowledge and understanding to do so. Staff must consistently and accurately complete the charts, evaluate the content of the charts and plan care accordingly. This is in order to comply with: SSI 2011/210 Regulation 15(b) (i) - staffing and SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health and welfare of people. page 14 of 43

15 This also takes account of National Care Standards, Care homes for older people, Standard 5 - Management and staffing arrangements should be taken into account when complying with this Requirement. Timescale: 4 weeks from receipt of this report. 2. Personal plans and associated risk assessments must accurately set out how service users' health, welfare and safety needs are to be met. In order to achieve this the provider must: a) ensure personal plans/risk assessments provide clear and accurate information to guide staff on how to meet the identified needs and risks b) ensure that the personal plans/ support plans and risk assessments accurately set out all aspects of the service users' current health and social care needs c) ensure that personal plans/support and risk assessments plans are effectively evaluated to make sure they are meeting residents' needs. This is in order to comply with: SSI 2011/210 Regulation 5 (1)(2)( b)(c) Personal Plans. This also takes account of National Care Standards, Care homes for older people, Standard 6 -Supporting Arrangements are taken into account. Timescale: 8 weeks from receipt of this report. Recommendations Number of recommendations The service provider should ensure that residents who require a soft diet have this appropriately presented at meal times and have ready access to suitable options outwith main meal times. This is to comply with National Care Standards - Care Homes for Older People, Standard 13 Eating Well. page 15 of 43

16 2. The service provider should ensure that plan of care for those residents who require medication for pain relief on an "as required" basis should be specific to meeting the needs of the individual. This is to comply with National Care Standards - Care Homes for Older People, Standard 15 Keeping Well - medication 3. The service provider should ensure that personal care needs of each resident are being met, staff practice is monitored and ensure associated records reflect the supports given. This is to comply with National Care Standards - Care Homes for Older People, Standard 5 Management and Staffing Arrangements page 16 of 43

17 Statement 5 We respond to service users' care and support needs using person centered values. Service strengths Our examination of records, observations of practice, discussion with residents, relatives, staff and the manager supported that the service performs at an adequate level in this quality statement. We heard from the registered manager that there are plans in place to use best practice material in relation to having a more person centred approach and for care and support to be more outcome focused. This means that care and support will be directed to meet the identified needs and preferences of each resident. We found that the service has carried out some work with the senior care staff to take this area forward. We observed staff profiles located on each floor which provides information on the staff members who look after them and encourages conversations about like minded interests. The staff within the service continue to liaise with other external healthcare professionals as and when required. Areas for improvement See comments within quality theme 1, statement 3 in connection with generic risk assessments and care plan material. Also see areas for improvement within theme 1, statement 3. Grade 3 - Adequate Number of requirements - 0 Number of recommendations - 0 page 17 of 43

18 Quality Theme 2: Quality of environment Grade awarded for this theme: 3 - Adequate Statement 2 We make sure that the environment is safe and service users are protected. Service strengths Our examination of records, observations of practice, environmental inspection, discussion with residents, relatives, staff and the manager supported that the service performs at an adequate level in this quality statement. The service has secure entry to the home with visitors required to sign in when they arrive in the building. This means that staff can monitor who is in the building at any given time. A risk assessment relating to the building has been carried out by the management team in January 2016 and reflects measures put in place for ensuring fire safety and risk assessments were in place for equipment used within the service. The service has a range of records which detail the checks carried out to the environment. We sampled records which detailed checks carried out to water temperatures, window restrictors and door closures. Areas for improvement Whilst accidents and incidents are recorded we were not always clear of the remedial actions/strategies adopted by management and staff to reduce the risk of recurrence. We shared examples with the registered manager and operations manager throughout the inspection. We expect improvements to be made in this area. These findings also relate to quality theme 4, statement 4. page 18 of 43

19 We found on the first day of inspection that care staff were required to carry out domestic activities (due to staff sickness and availability of domestic cover) and could see that this had an impact in their availability to meet the support and care needs of residents. We asked about the current shift pattern of domestic staff and concluded that this should be re-visited in order that there is greater accessibility of domestic cover and less need for care staff providing this type of support. We carried out an environmental inspection and identified a number of areas/ equipment that required cleaning, redecoration or repair. These included spillages on corridor walls, dirty bain maries used for holding food, pressure relieving equipment within bedrooms which required cleaning, bed bumpers in need of repair, carpet in a bedroom frayed and light bulbs within bathrooms needing replaced. We shall make a recommendation that the service adopts robust systems to ensure that standards of cleanliness and decoration improve. The service should also ensure that repairs are carried out timeously. See recommendation 1. We also identified poor practice in relation to staff not using appropriate equipment (bed bumpers) which we would expect to be in place to ensure the safety of individual residents. The registered manager was shown the specific concern we had with one resident during the inspection. There have been recent changes to the system used to request repairs and maintenance with a centralised electronic system being used. We looked at how this works through selecting two random requests for repairs requested early We found that there was difficulty in extrapolating records of completion. We concluded that further work is needed to be done in order that management can have a readily accessible system which provides clear information which reflects when works have been completed. Grade 3 - Adequate Number of requirements - 0 page 19 of 43

20 Recommendations Number of recommendations The service provider should adopt robust systems to ensure that standards of cleanliness and decoration improve. The service should also ensure that repairs are carried out timeously. This is to comply with National Care Standards - Care Homes for Older People, Standard 4.2 Your Environment. page 20 of 43

21 Statement 3 The environment allows service users to have as positive a quality of life as possible. Service strengths Our examination of records, observations of practice, environmental inspection, discussion with residents, relatives, staff and the manager supported that the service performs at a good level in this quality statement. We found that bedrooms are individualised with many residents bringing in personal effects when they move into the home. Bedrooms are of generous dimensions and all have en suite shower facility. We found the home to be barrier free for residents who have restricted mobility. Corridors have handrails in place and are spacious. There are a number of small seating areas located throughout the home for residents who may prefer to sit in a quieter area. We heard several positive comments from residents and relatives about the environment. These comments indicated that people found the home to be overall homely and clean. The home has attractive enclosed gardens which appear well maintained as well as seating near the front access. We observed visiting relatives spending time with their loved ones using these areas. There are good public transport links for visitors to the home with adjacent railways station and main bus route. The Home has their own transport for residents going on outings. Areas for improvement We identified that furniture within dining areas and communal areas either needed re-varnishing or replacement. We shall make a recommendation in connection with this area. See recommendation 1. Grade 4 - Good Number of requirements - 0 page 21 of 43

22 Recommendations Number of recommendations The service provider should ensure furniture in communal areas and dining rooms are either re-varnished or replaced. This is to comply with National Care Standards - Care Homes for Older People, Standard 4 Your Environment. page 22 of 43

23 Quality Theme 3: Quality of staffing Grade awarded for this theme: 2 - Weak 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 Our examination of records, interviews with staff and the manager supported that the service performs at a weak level in this quality statement. We examined six staff files to look at the recruitment procedures adopted by the service. All of the files contained a completed application form and each contained interview notes, letters of offer and contract of employment. Two of the six files contained a letter inviting the candidates to attend a five day induction programme composed of training in health & safety, fire safety, protection of vulnerable adults, customer care and personal care. This helps staff understand how they should carry out their role. The organisation offers work placements for individuals who have been unemployed, this gives individuals an opportunity to undertake training and build up skills to help equip them for applying for care assistant posts as well as providing the service with potential new employees. Areas for improvement We were informed that there had been changes made to the procedure used when recruiting staff and files were now held centrally at the service provider headquarters. We identified a number of important areas that should have been in place when recruiting new staff. Two of the six files sampled did not contain a PVG check from Disclosure Scotland. page 23 of 43

24 Only two files contained two written references (one being from the most recent or current employer). The remaining files detailed that there were three files which contained a character reference only and one which contained character references. We identified individuals who had been recently employed with another care provider and yet there were no references from the previous employer. We asked about checks with Scottish Social Services Council (SSSC; - this is the regulator of staff working within social care settings) prior to staff commencing employment and found that these are not being carried out by the service. We regard robust and safe recruitment practices to be essential for minimising potential risks to people who use the service. We shall make a requirement that the service provider adheres to safer recruitment practices through the uptake of references from current or most employer and carried pre-employment checks including checking the register with SSSC. See requirement 1. Grade 2 - Weak Requirements Number of requirements The service provider must make proper provision for the health, welfare and safety needs of service users. This is with specific reference to the safe recruitment of staff working in the service. In order to do this the service must undertake the following; Inspection report a) Review the policy and procedure for recruiting staff safely referenced to best practice guidance from the Scottish Government 'Safer Recruitment through Better Recruitment'. b) Adhere to best practice regarding the safe recruitment of staff. page 24 of 43

25 c) Obtain appropriate references including one from the current or most recent employer d) Check SSSC register prior to recruitment decisions about employment in the service being made. This is to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI2011/210), Regulations 4(1)a. Timescale - within three months of receipt of this report. Number of recommendations - 0 page 25 of 43

26 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths Our examination of records, interviews with staff and the manager supported that the service performs at a weak level in this quality statement. The service has recently introduced e-learning for staff. This training covers an appropriate range of training including challenging behaviour, pain management and dementia care. This has been supplemented with in-house training including encouraging food and fluid intake with residents. It appeared that approximately 80% of staff had undertaken the training however, it was difficult to extrapolate firm figures and we would suggest that this is an area that the service develops. The service should also provide clear information on refresher training to be undertaken and planned training. The management team have focused on developing a team of senior carers to assist with taking key areas of the service forward an example included undertaking training in supporting residents who may express stress and distress reactions. We looked at minutes of meetings between management and staff. Many of these were handwritten and these reflected management expectations of staff fulfilling their role. We found that in a set of minutes dated 22 April 2016 stated that all staff are now registered with SSSC. We make comment in connection with this in the areas for improvement section below. We observed polite and respectful interactions between staff and the residents that they support. We heard a number of positive comments from visiting relatives in connection with care staff;- see 'Taking Carers Views Into Account' section of the report. page 26 of 43

27 Areas for improvement When we arrived in the service we found that the staff levels were not as we would expect, we heard that this was due to short notice staff sickness. We also looked at staff rotas covering four weeks in May We shared examples of dates when the service had not adhered to the staffing schedule in terms of staff numbers and skill mix. According to the rotas there were two nights when there only five staff on shift, the service was mainly working with six staff on shift and occasionally seven staff. We found that there were three nights when there was only one nurse on shift when we would expect two. We looked at records associated with assessing the dependency levels of residents - there was no clear correlation between using these to inform how staff would be deployed to meet residents' needs. The dependency assessments do not take account of the size and layout of the care home. Based upon our findings we conclude that the service provider must ensure that there are appropriate staffing levels/skill mix to meet the needs of residents. We shall make a requirement in connection with this area. The above also relates to quality theme 4, statement 4, See requirement 1. We examined records relating to care staff employed within the service. We looked at records associated with the registration status of staff with SSSC - all care staff working in care homes for adults have been required to be registered with SSSC since September Registration with SSSC is a measure for employers to check the "fitness" of staff to work within their organisation. We found that there were a significant number of staff working within the service who were not currently registered with SSSC and this had not been identified by the service. We made further communications with the service provider to highlight that staff must register as a matter of urgency and communicated contingency arrangements must be put in place for providing cover for those staff who are not registered. We shall make a requirement in connection with this area. The above also relates to quality theme 4, statement 4. See requirement 2. Staff meeting minutes could be further developed by detailing action plans including reflecting which staff have been identified to take specific areas forward within timescales. page 27 of 43

28 We also found that the service could tap into best practice material including the Promoting Excellence Framework available through the SSSC website to help equip staff with necessary skills and knowledge for supporting residents living with dementia. Grade 2 - Weak Requirements Number of requirements The service provider must having regard to the size and nature of the care service, statement of aims and objectives and the number and needs of service users (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. This is to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI2011/210), Regulation 15 (a). Timescale - within 24 hours of receipt of this report. 2. The service provider must ensure that all care staff working within the service are registered with the regulatory body SSSC as a matter of priority and arrange staff cover for those staff who are not registered. This is to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI2011/210), Regulations 4 (1) Welfare of Users and regulation 9 (1) Fitness of Employees Timescale - within 24 hours of receipt of this report Number of recommendations - 0 page 28 of 43

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 Our examination of records, observations of practice, environmental inspection, discussion with residents, relatives, staff and the manager supported that the service performs at an adequate level in this quality statement. The service has carried out a survey with relatives and is currently working on collating the responses. There continues to be a suggestion box that visitors to the home can use. We heard that there have been some involvement from the manager in some of the care reviews carried out. We looked at complaints and found that there was information to support that the manager had met with a relative who had raised a complaint. We discussed how associated records needed to be developed to reflect investigation carried out to shape the planned actions to be taken. Areas for improvement We found a common theme emerging from interviews with relatives in connection with the need to make improvements with communications by the management team specifically in relation to the findings of the previous inspection of the service and events within the home. page 29 of 43

30 The service should look at how it can use a more proactive approach in involving key people such as relatives with the on-going improvement of the service and use the latest inspection report to help take this area forward. Relatives also shared that they found that communications could improve with staff who work on various shifts. Whilst it is encouraging to see that the manager has distributed and was in the process of collating the findings from surveys issued to relatives. We noted a number of less positive responses with the survey relating to communications from management, environment, staffing and activities. There was some information to suggest that the manager had met with individual relatives to discuss concerns. We recognise that the manager is still in the process of working with individuals who have raised concerns with the intention of building positive working relationships and plans to take areas forward with relatives. We believe that this is an important area that the service needs to develop. Grade 3 - Adequate Number of requirements - 0 Number of recommendations - 0 page 30 of 43

31 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 Our examination of records, observations of practice, environmental inspection, discussion with residents, relatives, staff and the manager supported that the service performs at a weak level in this quality statement. The Manager has worked on developing a quality folder and introducing new systems within the service in an attempt to take the service forward. We recognise that several of the systems have been implemented in recent months. We looked at a range of audits including care plan audits which we found to be detailed but did not reflect timescales for achievement. We looked at the meal time experience audit and could see that this is being used to monitor staff practice and we regarded as a positive development that residents had been involved in completing dining experience checklist. This provides direct feedback on this specific area for the management team. We found that the service had introduced protected meal times and we found that the service had responded to a requirement made at the previous inspection by involving care staff in a workshop to identify how the meal time experience of residents could improve. We could see that this had influenced some practices from our observations. Areas for improvement We acknowledge that there has been work carried out to develop a range of audits and systems in an attempt by the management team to take the service forward. However we found that there were not always clear recorded actions to address identified areas requiring improvement for example; ensuring care review meetings are planned and carried out as per current legislative requirements. page 31 of 43

32 We also looked at pressure wound monitoring records and looked at records relating to May 2016 and noted that residents we identified during inspection that currently had wounds were not included. The service should consider using best practice material such as the falls cross and pressure ulcer cross as a method for monitoring these key aspects of health and wellbeing of residents. We discussed throughout the inspection the need for clear and readily accessible systems to help the management team prioritise specific pieces of work and provide a record of progress being made. This included but was not limited to, the development of a staff training matrix and developing the staff supervision matrix. We have identified throughout the report important areas reflected as requirements and recommendations that the service must address. We conclude that the systems used by the service should have identified the same areas for improvement, help the management team prioritise work and should have effected change. Based upon our findings we have concluded that the requirement made at the previous inspection in connection with this area has not been met. See requirement 1. At the point of inspection there was no improvement or a development plan in place for the service, we suggest that this may help the management team identify key priorities, identify who is tasked to take specific areas forward, include timescales and be used to chart progress. Grade 2 - Weak Requirements Number of requirements The provider of a care service shall provide the service in a manner which promotes quality and safety. In order to do this, the Provider should continue to develop the quality assurance system to ensure that all aspects of the service are improved. page 32 of 43

33 Where required action has been identified as a result of an audit, the outcome should be clearly recorded to monitor improvement or if further action is needed. This is to comply with: SSI 2011/210 Regulation 3 Principles Timescale: 12 weeks from receipt of this report. Number of recommendations - 0 page 33 of 43

34 4 What the service has done to meet any requirements we made at our last inspection Previous requirements 1. The management of medications must be improved so that staff follow policy and best practice. In order to achieve this, the provider must: - demonstrate that staff follow policy and best practice about record keeping and documentation - demonstrate that staff follow policy and best practice when medication errors are discovered - provide training and refresher training appropriate to the safe management of medications - ensure there is a complete, accurate and consistent auditable record of all prescribed medications administered. This is in order to comply with: SSI 2011/210 Regulations 19 (j) a regulation regarding records registered care services must keep, 4 (1) (a) a regulation regarding the health, welfare and safety of service users and 15 (b) (i) a regulation regarding staffing. This also takes account of National Care Standards, Care homes for older people, standard 5 - Management and staffing arrangements and standard 15 - Keeping well - medication. Timescale: two months from receipt of this report. This requirement was made on 22 February 2016 See comments within quality theme 1, statement 3. Based upon our findings the requirement is met. Met - Within Timescales 2. The provider must improve the dining experience for residents. This is in order to comply with: SSI 2011/210 Regulation 3 Principles and SSI 2011/210 Regulation 4(1)(a) requiring proper provision for the health, welfare and safety of service users. page 34 of 43

35 This also takes account of National Care Standards, Care homes for older people, Standard 5 Management and staffing arrangements and Standard 13 Eating well. Timescale: One month from receipt of this report. This requirement was made on 22 February 2016 See comments in quality theme 1, statement 3. Based upon our findings the requirement is met. Met - Within Timescales 3. Personal plans and associated risk assessments must accurately set out how service users' health, welfare and safety needs are to be met. In order to achieve this the provider must: a) ensure personal plans/risk assessments provide clear and accurate information to guide staff on how to meet the identified needs and risks b) ensure that the personal plans/ support plans and risk assessments accurately set out all aspects of the service users' current health and social care needs c) ensure that personal plans/support and risk assessments plans are effectively evaluated to make sure they are meeting residents' needs. This is in order to comply with: SSI 2011/210 Regulation 5 (1)(2)( b)(c) Personal Plans. This also takes account of National Care Standards, Care homes for older people, Standard 6 -Supporting Arrangements are taken into account. Timescale: 8 weeks from receipt of this report. This requirement was made on 22 February 2016 See comments within "areas for improvement" quality theme 1, statement 3. Based upon our findings the requirement is not met. Not Met 4. The Provider must satisfy themselves that staff who complete observation charts such as daily fluid and food intake have the knowledge and understanding to do so. Staff must consistently and accurately complete the charts, evaluate the content of the charts and plan care accordingly. This is in order to comply with: SSI 2011/210 Regulation 15(b) (i) - staffing and SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health and welfare of people. page 35 of 43

36 This also takes account of National Care Standards, Care homes for older people, Standard 5 - Management and staffing arrangements should be taken into account when complying with this Requirement. Timescale: 4 weeks from receipt of this report. This requirement was made on 22 February 2016 See comments within "areas for improvement" quality theme 1, statement 3. Based upon our findings the requirement is not met. Not Met 5. The provider must ensure staff administer pain relieving medication as required for service users who may be suffering from discomfort/pain. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health and welfare of people This also takes account of National Care Standards, Care homes for older people, standard 5 - Management and staffing arrangements and standard 15 - Keeping well - medication. Timescale: On receipt of this report. This requirement was made on 22 February 2016 See comments within quality theme 1, statement 3. strengths and areas for improvement. On balance the requirement is met. Met - Within Timescales 6. The provider must ensure that all staff, including the management team at the service, are able to demonstrate a clear understanding of Adult Support and Protection Procedures. The provider must give notice to the Care Inspectorate within 24 hours of an allegation of misconduct which warrants investigation, dismissal or other disciplinary action. This is in order to comply with: SSI 2011/210: Welfare of users 4. (1) (a) make proper provision for the health, welfare and safety of residents and SSI 2011/ 210 regulation 9(1) - requirement about fitness of employees & SSI 2011/28 regulation 4(1)(b) - requirement about records, notifications and returns Timescale; Within 2 months of receipt of this report. This requirement was made on 22 February 2016 Inspection report page 36 of 43

37 There have been specific sessions carried out with staff within the care home and staff demonstrated a good understanding of the adult support and protection procedures. Based upon our findings we concluded that the requirement has been met. Met - Within Timescales 7. The provider must make proper provision for the health, welfare and safety of service users. In order to do this, they must ensure: Staff must ensure opened foodstuffs are labelled with an opening date to ensure they are safe for consumption. This is in order to comply with; SSI 2011/210 Regulation 4(1) (a) Welfare of Users and takes account of the National Care Standards, Care Homes for Older People. Standard 4 - your environment. Timescale; This was addressed in the course of the inspection visits. This requirement was made on 22 February 2016 We carried out an environmental inspection which included checking drinks and foodstuffs opened for consumption. We were satisfied that appropriate labelling and storage was carried out. Based upon our findings the requirement is met. Met - Within Timescales Inspection report The Provider must ensure that all staff have the necessary skills and training in order to meet the assessed needs of the resident group. In order to do this the Provider must: a) ensure there is a plan to address the deficits identified in staff training to detail when this training will be provided b) training to be provided must include but not be limited to the following: - dementia awareness - managing stress/distress - supporting residents to enjoy their meals. This is to comply with: SSI 2011/210 Regulation 4 (1) (a) (b) and (c) - Welfare of users, Regulation 9 (1) and (2) (b) - Fitness of employees and Regulation 15 (b) (4) - Staffing. page 37 of 43