New Calderglen Care Home Care Home Service Adults 1 Calderglen Avenue off Blantyre Farm Road Blantyre Glasgow G72 9UG Telephone:

Transcription

1 New Calderglen Care Home Care Home Service Adults 1 Calderglen Avenue off Blantyre Farm Road Blantyre Glasgow G72 9UG Telephone: Inspected by: Ann Marie Hawthorne Alison Iles Type of inspection: Unannounced Inspection completed on: 11 December 2012

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 6 3 The inspection 10 4 Other information 24 5 Summary of grades 25 6 Inspection and grading history 25 Service provided by: Heatherpost Limited Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Ann Marie Hawthorne Telephone enquiries@careinspectorate.com New Calderglen Care Home, page 2 of 27

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 3 Adequate Quality of Staffing 3 Adequate Quality of Management and Leadership 3 Adequate What the service does well The service is small and the staff team know the people they support well. The staff work closely with multi disciplinary teams seeking advice and guidance appropriately on how to meet individual needs. What the service could do better The service should develop an admission criteria and clear aims and objectives. Application of this would enable them to ensure that they do not admit people to the service unless they can meet their needs in line with their own criteria and in a way that reflects the National Care Standards. What the service has done since the last inspection The service had made progress in some areas since the last report. This is discussed more fully within the body of this report. The service has not yet submitted plans to the Care Inspectorate for the extension to the building. Conclusion The service is provided within a listed building in a semi rural location and the environment does not provide people with the opportunity to have choice in relation to where they spend time outwith their own bedroom and one communal sitting area. This home is not designed to provide people with the opportunity to maintain or New Calderglen Care Home, page 3 of 27

4 develop skills independently e.g making tea, meals, laundry etc.. In this respect, the service has accepted referrals for some people for whom they subsequently find cannot have their needs met effectively within the service. They need to address this for present residents while ensuring that they review their referral criteria and apply this for those people who are referred to the service in the future. Who did this inspection Ann Marie Hawthorne Alison Iles New Calderglen Care Home, page 4 of 27

5 1 About the service we inspected New Calderglen is a Care Home on the outskirts of Blantyre. It is run by a company called Heatherpost. The owner has four other companies and care homes in Scotland. Following a variation to its existing conditions of registration the home was now registered to provide a 'care service to 28 adults (older people and younger adults) with mental health problems, alcohol related problems and associated physical or sensory impairment'. Care can be long term or on a short stay respite basis. At the time of the inspection the home had no vacancies. Accommodation is in a converted 19th century baronial style house. The home's philosophy of care includes providing a secure safe and homely environment for residents, relatives and staff which is achieved by a professional and caring team'. Before 1 April 2011 this service was registered with the Care Commission. On this date the new scrutiny body, the Care inspectorate took over the work of the Care Commission, including the registration of care services. This means that from 1 April 2011 this service continued its registration under the new body. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 4 - Good Quality of Environment - Grade 3 - Adequate Quality of Staffing - Grade 3 - Adequate Quality of Management and Leadership - Grade 3 - Adequate This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. New Calderglen Care Home, page 5 of 27

6 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 The service was inspected across one day by two inspectors. Feedback was provided to the service at a meeting on a second day. The inspection involved meeting with Manager and staff, discussion with visiting health professionals, discussion with residents, observation of practice, review of the environment, review of service policies, review of personal plans, medication processes and audit materials. 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 New Calderglen Care Home, page 6 of 27

7 What the service has done to meet any requirements we made at our last inspection The requirement Proposed Extension: Managers and staff need to discuss what layout will best meet the needs of the present group of residents and advise the owner and architect. Given the complex needs of the present client group discussions should also include what is the maximum number of people the home should be catering for. The owner and architect need to take full account of this. The owner should submit revised clear detailed plans for the extension. The owner should provide a timescale for the start and completion of the extension. What the service did to meet the requirement No action has been taken in relation to this requirement, this requirement has been reviewed as detailed in quality theme 2.2. The requirement is: Not Met The requirement Extension The managers and staff need to discuss what layout will best meet the needs of the present group of residents and advise the owner and architect. Given the complex needs of the present client group discussions should also include what is the maximum number of people the home should be catering for. The owner and architect need to take full account of this. The owner should submit revised clear detailed plans for the extension. The owner should provide a timescale for the start and completion of the extension. The owner should now make an application to the Care Inspectorate to vary the homes conditions of registration with a view to starting the process needed for increasing capacity when the extension is built.timescale: immediate. What the service did to meet the requirement No action has been taken on this requirement. this requirement has been reviewed as detailed in quality theme 2.2. The requirement is: Not Met New Calderglen Care Home, page 7 of 27

8 The requirement The owner should provide the Care Inspectorate with a current business plan for Heatherpost and his most recent statement of annual accounts/cash flow forecast. Timescale: immediate. What the service did to meet the requirement No action has been taken on this requirement The requirement is: Not Met Inspection report continued The requirement Grounds The piece of ground across from the driveway just beyond the gas storage tankers and visible from the home should be cleared of rubbish and kept clear. Timescale: immediate. These requirements are made to comply with SSI 2011/210 Fitness of premises 10.-(1). A provider must not use premises for the provision of a care service unless they are fit to be so used. (2) Premises are not fit to be used for the provision of a care service unless they- (a)are suitable for the purpose of achieving the aims and objectives of the care service as set out in the aims and objectives of the care service; (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. What the service did to meet the requirement The grounds had been cleared of rubbish. The requirement is: Met What the service has done to meet any recommendations we made at our last inspection There were no recommendations in the last inspection report 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 New Calderglen Care Home, page 8 of 27

9 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 self assessment was submitted and contained an appropriate level of detail. Taking the views of people using the care service into account The people who spoke to us and were using this service told us that they liked the service. They said the staff were really good. One person told us that the staff work hard and seek help when they need to. Taking carers' views into account We did not have access to carers during this inspection. New Calderglen Care Home, page 9 of 27

10 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: 4 - Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths The service did demonstrate that they have introduced a range of methods including a newsletter to facilitate and encourage participation from residents and their families in the service. Their is a participation policy in place, however many of the residents using this service do not have active input from others in their lives. Where families and significant others are involved they are encouraged to participate and support people to in decisions about the way in which the service is provided. We saw that the staff team have tried a range of methods to engage people in this. The service tries to be creative about involving people and have identified that the most successful way to get involvement is through holding social and recreational events and inviting friends and family members. During the course of the event / activity staff will liaise and engage with people to seek their views on the way in which the service is provided. In addition to this we saw that some people are supported to use advocacy services. Areas for improvement The service would benefit from reviewing the participation policy to ensure it accurately reflects a statement about what participation is. The service would further benefit from ensuring that all staff have an understanding of the participation policy and are aware of ways in which they could optimise the involvement of the people using the service, and, where possible their families or carers, in all matters relating to the service (see recommendation 1). This statement captures the way in which the service can improve participation for this service across all quality themes. New Calderglen Care Home, page 10 of 27

11 Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. The service should review the participation policy ensuring that the meaning and purpose of participation is more clear in the policy. They should also take steps to ensure that all staff are aware of the importance of participation and ways in which they can be involved in influencing the delivery of this service. National Care Standards 11 Care Homes for People with Mental Health Problems - Expressing Your Views Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths The service has evidence that they meet many of the the diverse health needs of the people they support. The service supports people who have a range of complex physical health needs and those who experience issues with addictive behaviours, mental ill health and dementia. The team work closely with a range of health agencies on an individual needs led basis to ensure that they are supporting people in line with professional advice and guidance. We saw evidence of this reflected through detailed support plans which clearly evidence information provided by the multi disciplinary teams. All of the staff we spoke with were aware of the needs of the people who are supported by this service and of the support strategies which work best for each individual. We saw that support plans are reviewed to reflect that needs have changed. The service also supports people who have Learning Disabilities and a range of complex needs, again there is evidence that they seek the support of the Learning Disability team to help them to develop skills which enable them to subsequently support people well. We saw a good level of input across a broad range of physical health needs, for example, attention to detail in relation to oral health, access to fluids throughout the day, a good range of nutritional food reflected in the menu choices offered. We observed the mealtime experience and saw that people were also supported and encouraged to eat well. People who use the service told us that the food is always good and that they always get enough to eat, we saw people being offered the choice of additional food. New Calderglen Care Home, page 11 of 27

12 The service operate a monthly review process and for some this ensures that support is adjusted to meet needs as necessary. The service have developed a formal link with South Lanarkshire Social Work Department to ensure that they have active external input to reviewing the needs of residents. The service also has good links with the GP practice. the practice are responsive and visit the service frequently. We also saw evidence that where there is indication that people may lack capacity to make decisions about their own health, assessments have been carried out and the appropriate documentation reflecting legislation and best practice is in place. We saw some evidence that activities take place and people are supported to go of the home at times. In general we saw evidence of good support planning and care delivery, people looked well and all those we spoke to told us that they were happy with the service. Areas for improvement Inspection report continued We saw that the service has admitted some people who have multiple and complex needs which cannot be met fully within this service, for example, where rehabilitation and development of skills for independent living is a key outcome for people, the admission takes place in the knowledge that the service does not offer this kind of support. This could result in the loss of skills for individuals and admission to this service may not be in the best interest of all those receiving support. In addition to this, while the staff team work hard to meet the complex needs of individuals who have been admitted to the service, the level of complexity evident in the needs presented can mean that this service is not appropriate to meet their needs (Requirement 1). We saw evidence that the staff team do not fully complete the Medication Administration Records to reflect any variation on administration, for example, missed or refused medication (Requirement 2). We saw that the temperature recording of the fridge used to store medicines was recording a temperature in excess of 8 on a frequent basis and that no action had been taken to address this (Requirement 3). People were observed to spend a lot of time watching television or smoking and while we recognise that the service do provide structured themed activities we think they could do more to engage people in some activity throughout their everyday lives (Recommendation 1). We discussed episodes of challenging behaviour which we saw reported in documentation and from this discussion we identified that the service needs to develop their understanding of what constitutes challenging behaviour and was in New Calderglen Care Home, page 12 of 27

13 which such episodes should be managed and reported in line with best practice and Adult Support and Protection guidance (Recommendation 2). Grade awarded for this statement: 4 - Good Number of requirements: 3 Number of recommendations: 2 Requirements 1. The Provider must ensure that the aims, objectives and admission criteria for this service is reviewed and subsequently adhered to. The provider must thereafter ensure that people admitted to this service can have their assessed needs met within this criteria. 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. Timescale: within 4 weeks of receipt of this report. 2. The provider must ensure that medication is recorded in a manner which provides detail of the reason for varying the information in the prescription. 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. Timescale: within 24 hours of receipt of this report. 3. The provider must ensure that equipment used to store medicine at a refrigerated temperature is fit for purpose and that where the monitoring of the temperature falls outwith 2-8 prompt and appropriate action is taken to rectify this. This is to comply with SSI 2011/210;14 The Provider must, having regard to the size of the service, the statement of aims and objectives and the number and needs of service users (b) provide such other equipment for the general use of Service Users as is suitable and sufficient having regard to their health and personal care needs. Timescale: within 24 hours of receipt of this report. Recommendations Inspection report continued 1. The service should develop a system to ensure that people are offered the opportunity to engage in a range of activities of their choice throughout the day. National Care Standards, Standard 10 Care Homes for People with Drug and Alcohol Misuse Problems - Lifestyle - Social, Cultural and Religious Belief or Faith. New Calderglen Care Home, page 13 of 27

14 2. The service should review the way in which they define challenging behaviour and should review the adult support and protection policy with all staff to ensure that they understand their responsibilities in relation to managing and reporting concerns. They should use this process to identify staff training needs in relation to challenging behaviour. NCS 4 Care Homes for People with Drug and Alcohol Misuse Problems - Management and staffing arrangements (for services in a care home). New Calderglen Care Home, page 14 of 27

15 Quality Theme 2: Quality of Environment Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths We spoke to people who use the service and they told us that they were involved in making choices about their own bedroom areas. One person did not know that it was possible to have a key of their own for the bedroom, this was addressed and remedied during the period of inspection. For further detail on this quality theme please see Quality Theme 1.1 Areas for improvement Please see Quality Theme 1.1 Grade awarded for this statement: 4 - Good 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 Within the limitations presented by the physical layout of this home, the staff do try to ensure that the environment is safe and that people residing in this home are safe. The manager of the service notifies the Care Inspectorate appropriately of issues which arise in relation to maintaining safety within the home. There are a range of risk assessments which are regularly reviewed and there is active input from external agencies including fire regulation and safety, advocacy services, learning disability teams and social work services. Areas for improvement The environment presents hazards in relation to the physical layout of the building, for example, the design of the stairs and the general layout of the building. The lack of communal space means that people spend considerable time with others who have a range of complex communication or behavioural issues. Our observations on the day New Calderglen Care Home, page 15 of 27

16 of the inspection, and in the review of documentation we looked at, suggests that this often leads to people becoming fractious with each other. Previous inspection reports highlight this issue and requirements to provide alternative accommodation in the form of an extension to the building for residents have not been met and have been repeated in more than one inspection report. This requirement is now being altered to focus on the needs of the people using the service and on the aims and objectives of the service. This is because the provider has not taken steps to develop the extension to the service which is described in previous reports. The service therefore needs to provide a service only to those individuals who can have their needs met fully and safely within the service in its present layout (Requirement 1). We saw evidence that some risk assessments are not signed or dated (Recommendation 1). There was a risk assessment to ensure safety in relation to the use of the designated smoking area, this stated that individuals would be observed while using this facility. We did not see observation being carried out while the area was in use on the day of inspection. We also observed people receiving support to light a cigarette outwith the designated smoking area, this resulted in them walking through the service with a lit cigarette (Requirement 2). We saw one bed with broken bed rails and we were advised that a repair had been requested however there was no note or evidence of this, this will be followed up at the next inspection (Recommendation 1). Grade awarded for this statement: 3 - Adequate Number of requirements: 2 Number of recommendations: 1 Requirements 1. The Provider must, in consultation with all stakeholders, review the structural layout of this service and ensure that the aims and objectives of the service and the needs of the service user's can be met within the physical environment provided. As part of this process the provider must consider the number of residents who can be adequately supported within the environment not only in bedroom capacity, but also in relation to communal space. The provider must send detail of the outcome of this review to the Care Inspectorate. This is to comply with SSI 2011/210 (10) Fitness of Premises. Timescale: Within 4 weeks of receiving this report Inspection report continued 2. The provider must ensure that risk assessments are reviewed in relation to smoking within the care home and that staff comply with and follow the outcome of the risk assessment for each individual.the practice of lighting cigarettes outwith the designated smoking area must stop. New Calderglen Care Home, page 16 of 27

17 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. Timescale; Within 24 hours of receiving this report Inspection report continued Statement 3 The environment allows service users to have as positive a quality of life as possible. Service strengths This service is provided within a former stately home which has been adapted to create a care home. It was evident that most people have a bedroom area which is fit for purpose. We saw that some were furnished using the individual's own personal items and looked very homely and personal. The home in general appeared clean and comfortable and there were a number of domestic staff in the service on the day we visited. Areas for improvement There is only one shared living area on the ground floor of the home. This means that the 27 residents who were living in the care home at the time of inspection can only choose to either sit in this area or go to their bedroom. There is a very small sitting area on the top floor of the home which does offer a quiet space, but is inaccessible to many of the residents. Some people choose to sit on the stairs which are a central feature in the main entrance foyer, this enables them to see the activity of those entering and leaving the home but does not look dignified or comfortable and creates a hazard for those using the stairs. Some others choose to sit in this entrance on a chair or in their wheelchair (see statement 2 requirement 1). During the inspection we identified that one resident had been admitted to the home for a period of respite and was using a shared bedroom. The bedroom was that of a resident who lived permanently within the home. This compromised the privacy, dignity and respect of both residents (Requirement 1). In discussion with the staff team we identified that this issue arose due to the lack of a clear admission criteria and that it highlights the need to review the aims and objectives for this service (see quality theme 1.3 requirement 1). During the time we were in the service we did not see much staff interaction with residents in relation to activities. Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 1 New Calderglen Care Home, page 17 of 27

18 Requirements 1. The provider must not admit any resident to the service unless the environment being offered to them meets their assessed needs and affords them the opportunity to have privacy dignity and choice respected in relation to their accommodation. In addition the provider must not compromise the privacy dignity and choice of people presently residing in this home in order to accommodate new admissions. This is in order to comply with SSI 2011/210 (4) Welfare of Users and SSI 2011/210 (10) (a) Fitness of Premises. Timescale: Within 24 hours of receiving this report. Recommendations Inspection report continued 1. The service should review the way in which people spend their time throughout the day within this service and facilitate activities that people can engage in with all staff. National Care Standards 10 Care Homes for People with Drug and Alcohol Misuse Problems - Lifestyle - Social, Cultural and Religious Belief or Faith New Calderglen Care Home, page 18 of 27

19 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths Please see Quality Theme 1, statement 1 Areas for improvement The service would benefit from involving the people who receive support in assessing the quality of staffing in this service. While they do acknowledge the opinions of the residents in relation to the staff they have not yet developed a formal method of engaging them in this process (Recommendation 1). Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service should consider ways in which they can seek the views of residents their relatives/carers in relation to the quality of the staff from recruitment, in supervision and appraisal. National Care Standards 9 Care Homes for People with Drug and Alcohol Misuse Problems - Expressing Your Views 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 been supporting the staff team to achieve Scottish Vocational Qualifications at levels 2 and 3 in social care. At the time of inspection SVQ 2 had been achieved by 7% of staff and SVQ 3 by 76% of staff. All staff are registered with the Scottish Social Services Council. The manager of the service provided us with a list of training which had been carried out with staff which included mandatory training New Calderglen Care Home, page 19 of 27

20 and training in, for example, Adults with incapacity, continence, oral hygiene, addictions. We spoke with staff who confirmed that they were well supported in their training within this service. Staff meetings take place regularly and minutes reflect that a broad range of policies are discussed in this forum. Areas for improvement The manager does not have a training matrix or training needs analysis which would allow a view to be taken in relation to the training needs of all staff. The lack of a training matrix makes if difficult to establish the way in which the service considers the continuing professional development needs of the staff team, the manager had told us during the previous inspection that a training plan would be developed. (Recommendation 1). We saw evidence that staff meetings do take place but that where issues are identified and action is required to address issues there is no follow up noted (Recommendation 2). Supervision does take place but the evidence we saw indicates that this is annual. Appraisals do take place annually however the service uses two different formats for appraisal and would benefit from selecting one of these as a consistent appraisal tool. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 2 Recommendations Inspection report continued 1. The Manager should develop a training matrix to plan and evidence the status of training for the staff working within this service. National Care Standards 4 Care Homes for People with Drug and Alcohol Misuse Problems - Management and staffing arrangements (for services in a care home) 2. The Manager should develop a method of evidencing that issues raised within meetings which take place within the service are addressed and that the outcome is communicated to all relevant parties. National Care Standards 17 Care Homes for People with Drug and Alcohol Misuse Problems - Management and staffing arrangements (for services in a care home) New Calderglen Care Home, page 20 of 27

21 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths The service has evidence that they attempt to engage residents families and carers in assessing and improving the quality of management and leadership within this service. The do this through social events, newsletters and questionnaires but have identified that the most effective mode is in discussion with people when they visit the service. Areas for improvement The service does not capture or reflect the way in which people who use the service, their families or carers are involved in or influence the quality of management and leadership within the service (Recommendation 1). Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service should continue to encourage the participation of residents families and carers in the leadership and management of this service in the ways detailed in this report but should capture and reflect all input that they have. National Care Standards 9 Care Homes for People with Drug and Alcohol Misuse Problems - Expressing Your Views 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 manager has a strong presence within this service and has a range of systems and processes in place which are monitored to ensure that these are adhered New Calderglen Care Home, page 21 of 27

22 to. There are a range of meetings which take place to review the quality of the service. An audit system was in place at the time of the inspection. Care and support audits are carried out monthly and we saw that an audit had been carried out a few weeks before the inspection. We saw evidence that where care plan audits had identified areas which needed to be addressed that this was signed off as being carried out. Environmental audits take place and a maintenance log is kept. Questionnaires were used and feedback was sought from individuals during the review process. Where the service had received complaints we saw that appropriate action was taken to address the area of concern. Areas for improvement We saw that some audits being completed were not signed or dated. We also saw that action plans were not always developed where areas for improvement were identified. The service needs to ensure the audit process is complete and we will look at how they have addressed this during the next inspection. The medication audit is carried out by the pharmacy supplier and not by the service, there was no evidence that actions identified by the pharmacy supplier had been taken forward (Recommendation 1). The service has a complaints folder which has a number of different procedures within it (Recommendation 2). Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 2 Recommendations Inspection report continued 1. The service needs to develop an action plan for both internal and external audit activity ensuring that areas which require to be addressed are recorded and clearly evidence action which is to be taken, by whom and by a specific date. This should then be recorded as complete and signed off as such. National Care Standards, standard 4 Care Homes for People with Drug and Alcohol Misuse Problems - Management and staffing arrangements (for services in a care home). 2. The service should review the complaints policy and procedure and ensure this is used consistently removing all other formats from the service. New Calderglen Care Home, page 22 of 27

23 National Care Homes, Standard 1 Care Homes for People with Drug and Alcohol Misuse Problems - Informing and Deciding. New Calderglen Care Home, page 23 of 27

24 4 Other information Complaints There has been one complaint upheld since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information 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). New Calderglen Care Home, page 24 of 27

25 5 Summary of grades Quality of Care and Support Good Statement 1 Statement Good 4 - Good Quality of Environment Adequate Statement 1 Statement 2 Statement Good 3 - Adequate 3 - Adequate Quality of Staffing Adequate Statement 1 Statement Adequate 4 - Good Quality of Management and Leadership Adequate Statement 1 Statement Adequate 4 - Good 6 Inspection and grading history Date Type Gradings 23 Mar 2012 Unannounced Care and support 4 - Good Environment 3 - Adequate Staffing 4 - Good Management and Leadership 4 - Good 22 Nov 2011 Unannounced Care and support 3 - Adequate Environment 3 - Adequate Staffing 3 - Adequate Management and Leadership 3 - Adequate 15 Dec 2010 Unannounced Care and support 4 - Good Environment 3 - Adequate Staffing Not Assessed New Calderglen Care Home, page 25 of 27

26 Management and Leadership Not Assessed 30 Sep 2010 Unannounced Care and support 4 - Good Environment 3 - Adequate Staffing Not Assessed Management and Leadership Not Assessed 31 Mar 2010 Unannounced Care and support 4 - Good Environment 3 - Adequate Staffing 4 - Good Management and Leadership 4 - Good 30 Oct 2009 Announced Care and support 4 - Good Environment 3 - Adequate Staffing 4 - Good Management and Leadership 4 - Good 31 Mar 2009 Unannounced Care and support 4 - Good Environment 3 - Adequate Staffing 4 - Good Management and Leadership 4 - Good 11 Jul 2008 Care and support 4 - Good Environment 3 - Adequate Staffing 4 - Good Management and Leadership 4 - Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. New Calderglen Care Home, page 26 of 27

27 To find out more about our inspections and inspection reports Read our leaflet 'How we inspect'. You can download it from our website or ask us to send you a copy by telephoning us on 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: New Calderglen Care Home, page 27 of 27