Glenlivet Gardens Care Home Care Home Service Adults Glenlivet Place Darnley Glasgow G53 7LA

Transcription

1 Glenlivet Gardens Care Home Care Home Service Adults Glenlivet Place Darnley Glasgow G53 7LA Inspected by: Drew Conlon Sarah Gill Type of inspection: Unannounced Inspection completed on: 7 August 2012

2 Contents Page No Summary 3 1 About the service we inspected 4 2 How we inspected this service 5 3 The inspection 8 4 Other information 17 5 Summary of grades 18 6 Inspection and grading history 18 Service provided by: JSL Care Ltd Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Drew Conlon Telephone enquiries@careinspectorate.com Glenlivet Gardens Care Home, page 2 of 20

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 4 Good Quality of Environment 4 Good Quality of Staffing 4 Good Quality of Management and Leadership 4 Good What the service does well The service fosters a relaxed and friendly attitude to its care giving and has a committed group of staff. What the service could do better The service wants to seek and retain more views from health professionals and other stakeholders about the quality of its service. What the service has done since the last inspection The service has continued strengthening the participation opportunities for both its service users and their relatives. Conclusion A committed staff group work hard, both to maintain standards and to improve the service whenever they can. Who did this inspection Drew Conlon Sarah Gill Glenlivet Gardens Care Home, page 3 of 20

4 1 About the service we inspected Glenlivet Gardens Care home provides accommodation for up to 48 older people. The building is purpose built on two levels. There is an enclosed garden area to the rear. All bedrooms offer single accommodation with en-suite facilities. It is situated in a residential area of south Glasgow, near to public transport and community resources. The service is provided by JSL Care Limited. Before 1 April 2011 this service was registered with the Care Commission. On this date, the new scrutiny body, Social Care and Social Work Improvement Scotland (the Care Inspectorate), took over the work of the Care Commission including the registration of services. This means that from 1 April 2011, this service continued its registration under the new body, the Care Inspectorate. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade Quality of Environment - Grade Quality of Staffing - Grade Quality of Management and Leadership - Grade 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. Glenlivet Gardens Care Home, page 4 of 20

5 2 How we inspected this service The level of inspection we carried out In this service we carried out a low intensity inspection. We carry out these inspections when we are satisfied that services are working hard to provide consistently high standards of care. What we did during the inspection The evidence for this report was gathered by Drew Conlon and Sarah Gill, Inspectors. They visited the service over two days on Monday 6 August from 09:30 hours to 16:30 hours and on Tuesday 7 August from 09:45 hours to 16:15 hours. During this time they spoke with the service manager, the depute manager, two staff nurses, a senior carer, an activities organiser and a number of care assistants. They also spoke with seven service users and four relatives. The comments of service users and relatives in eleven returned questionnaires were also considered. In addition a wide range of policies and procedures and other related documentation was also considered including; Care plans. Relatives' meeting minutes. Accident and incident records. Medication policy. Records of health and safety checks. Training records. Staff supervision records. Glenlivet Gardens Care Home, page 5 of 20

6 Grading the service against quality themes and statements We inspect and grade elements of care that we call 'quality themes'. For example, one of the quality themes we might look at is 'Quality of care and support'. Under each quality theme are 'quality statements' which describe what a service should be doing well for that theme. We grade how the service performs against the quality themes and statements. Details of what we found are in Section 3: The inspection Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at Glenlivet Gardens Care Home, page 6 of 20

7 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. All the sections of the self assessment were completed. Taking the views of people using the care service into account The views of service users were favourable. 'The staff are very good and I get anything I need done, completed in minutes'. 'The staff are really nice, it's my 21st birthday again and they have made me a cake!'. 'The staff take a lot of trouble and it's a very clean home'. Taking carers' views into account The views of relatives were favourable. 'I find the staff of Glenlivet Gardens to be very friendly and approachable'. 'My initial impressions are very positive and confirmed by talking to other relatives who have been visiting for a longer time'. Glenlivet Gardens Care Home, page 7 of 20

8 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: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths The service has a strong participation strategy including a number of ways service users and relatives can comment and be involved. There is a system for service users' meetings. The service user who led this process has recently passed away and the home manager is seeking another service user to take on this role. There was evidence of active use of questionnaires to seek service users' and relatives' views. There is an effective system to ensure care plans are reviewed on time. Contacts with visiting health professionals and relatives were clearly recorded in care plans. Areas for improvement The review of care plans and of risk assessments could be more closely linked to each other. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Glenlivet Gardens Care Home, page 8 of 20

9 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths There was evidence from care plans of constructive engagement with a wide variety of health professionals. There is a specific group that seeks service users' views on food and menu choices. There was evidence of a range of activities both in and out of the home. There has been, for instance, a dominoes competition with another care home. Records are kept of service user's participation in different activities. A service user spoke with pleasure of being able to use Skype to talk to family in Australia. An IPad is now available so Skype can be used in a service user's own bedroom. There are well established systems to allow service users to comment on food and menus. Areas for improvement There should be a process for evaluating the activities programme against best practice guidance and for regular review and improvement where possible. In the case of one person with a pressure sore, there were issues about wound assessment and care plan recording not being up to date. This is the subject of Requirement 1 below. One service user was receiving medication administered covertly. The consents and authorisations for this had been established correctly. However, there were aspects of subsequent practice that could be improved. This is the subject of Recommendation 1 below. Grade awarded for this statement: Number of requirements: 1 Number of recommendations: 1 Requirements 1. Requirement with reference to Theme 1, Statement 3: The provider should ensure that pressure sore assessment, care planning and recording is kept up to date. The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 Number 4(1) (a) - make proper provision for the health, welfare and safety of service users. Timescale for implementation - From the date of receipt of this report. Glenlivet Gardens Care Home, page 9 of 20

10 Recommendations Inspection report continued 1. The provider should ensure that in any instances of administration of covert medication, the principles and practice published in 2006 by the Mental Welfare Commission for Scotland are followed. National Care Standards: Care Homes for Older People; Care Standard Number 14 - Keeping well. Glenlivet Gardens Care Home, page 10 of 20

11 Quality Theme 2: Quality of Environment Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths There was evidence the home manager has sought views on the development of the gardens and making access to the gardens by patio doors. The refurbishment of a small ground floor lounge has also been discussed and progressed. The environment is a continuing item on the agenda for meeting with relatives. The questionnaires for service users ask if they are happy with their rooms and if they are kept neat and tidy. Areas for improvement There were areas of staining on corridor carpets. The service has recognised this and is arranging for replacements with carpets of a higher stain resistant standard. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Glenlivet Gardens Care Home, page 11 of 20

12 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths A task list for the deep cleaning of rooms was seen. This cleaning cycle was an item for discussion at housekeeping meetings. Records of electrical checks on portable electrical appliances were seen. There was evidence of testing the water temperature in service users' rooms. There is also a system of bed rail safety checks. Any accidents are recorded and analysed. Areas for improvement The service will ensure that risk assessments on equipment used are formally considered as part of a six monthly review of care plans. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Glenlivet Gardens Care Home, page 12 of 20

13 Quality Theme 3: Quality of Staffing Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths Opportunities for relatives to comment and participate are a particular strength. The home has two meeting opportunities for relatives. The first is a meeting the manager attends. The second is a relatives meeting, used as a mutual support group. The manager does not routinely attend but will attend if invited. The relative's support group has prepared a written welcome sheet for relatives newly in contact with the home. It acknowledges entry into a care home can be a worrying time for relatives and lists some helpful suggestions. Service users have made contributions to the staff recruitment process and the questions asked at interviews. The service questionnaire includes opportunities for service users to comment on whether their wishes are respected and on, for instance, the approachability of staff. Areas for improvement The provider should consider how service users could contribute to staff induction and training.this is the subject of Recommendation 1 below. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. Recommendation with reference to Theme 3, Statement 1: The provider should explore opportunities for service users and relatives to contribute to staff induction and training. National Care Standards: Care Homes for Older People: Care Standard Number 11 - Expressing your views. Glenlivet Gardens Care Home, page 13 of 20

14 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths A number of relatives said staff were motivated to do their best for service users and staff tried to be as flexible as they could. Supervision records were sampled and included a number of constructive contributions by care staff to the overall process. There was evidence of a wide variety of training courses being available. These included falls awareness, tissue viability, records and record keeping and dementia awareness. There was evidence of awareness of good practice guidance. An example of this was awareness of the NHS Scotland and Care Inspectorate's good practice self assessment resource on 'Managing falls and fractures in care homes for older people'. Areas for improvement The supervision system could contain more specific training needs analysis. There had been a gap in the frequency of staff meetings. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Glenlivet Gardens Care Home, page 14 of 20

15 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths The strengths of the participation structure which are noted under previous Statements also apply to this Statement. At a meeting with relatives on May 25 this year, the home manager confirmed how she could be contacted and the company directors would also make themselves available if requested. The manager intends to trial a Saturday morning surgery for any relatives who have commitments during the week. There was evidence that comments and suggestions are encouraged and then responded to. Areas for improvement The service would benefit from methods more specifically addressing the issues of management and leadership in seeking the views of service users and relatives. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Glenlivet Gardens Care Home, page 15 of 20

16 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 has a Quality Assurance policy. There was evidence of audit systems and self-assessment check lists. In the audit system for care plans, there are timescales for the completion of any documentation needing updated. The auditing of any accidents or injuries is completed on a monthly basis. It includes, for instance, the location of any accidents and confirmation that relatives were kept informed. Areas for improvement The service could have a more systematic method of gaining and retrieving the views of stakeholders, like care managers or visiting health professionals. This is the subject of Recommendation 1 below. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 1 Recommendations 1. Recommendation with reference to Theme 4, Statement 4: The provider should arrange a method to more systematically record the views of relevant stakeholders on the quality of the service provided. National Care Standards: Care Homes for Older People - Care Standard Number 11- Expressing your views. Glenlivet Gardens Care Home, page 16 of 20

17 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 N/A. Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). Glenlivet Gardens Care Home, page 17 of 20

18 5 Summary of grades Quality of Care and Support - Statement 1 Statement 3 Quality of Environment - Statement 1 Statement 2 Quality of Staffing - Statement 1 Statement Very Good Quality of Management and Leadership - Statement 1 Statement 4 6 Inspection and grading history Date Type Gradings 21 Feb 2012 Unannounced Care and support Environment Not Assessed Staffing Management and Leadership Not Assessed 31 Oct 2011 Unannounced Care and support Environment Not Assessed Staffing Management and Leadership Not Assessed 12 Jan 2011 Announced Care and support Environment Staffing Not Assessed Management and Leadership Not Assessed Glenlivet Gardens Care Home, page 18 of 20

19 14 Jul 2010 Unannounced Care and support Environment Staffing Not Assessed Management and Leadership Not Assessed 5 Mar 2010 Unannounced Care and support Environment Staffing Management and Leadership 18 Sep 2009 Unannounced Care and support Environment 3 - Adequate Staffing 3 - Adequate Management and Leadership 3 - Adequate All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Glenlivet Gardens Care Home, page 19 of 20

20 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 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: or by telephoning Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: enquiries@careinspectorate.com Web: Glenlivet Gardens Care Home, page 20 of 20