Care service inspection report Full inspection Clashfarquhar House Care Home Service 23 Robert Street Stonehaven Inspection completed on 03 May 2016
Service provided by: Church of Scotland Trading as Crossreach Service provider number: SP2004005785 Care service number: CS2003000266 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 0345 600 9527 www.careinspectorate.com @careinspect Inspection report page 2 of 31
Summary This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change after this inspection following other regulatory activity. For example, if we have to take enforcement action to make the service improve, or if we investigate and agree with a complaint someone makes about the service. We gave the service these grades Quality of care and support 5 Quality of environment Quality of staffing Quality of management and leadership 4 Very Good N/A N/A Good What the service does well The focus was clearly on the delivery of a service that respected people's wishes, choices and preferences. We found the atmosphere in the home to be very warm and welcoming. The interactions between staff and residents were observed to be open and friendly. Discussions with staff and observation of practice demonstrated an understanding of residents' needs. What the service could do better Further development of care documentation was needed, specifically when assessing and planning for more complex health and social care needs. There needed to be consistency in the completion of medication administration records (MARs). page 3 of 31
Further development of protocols for 'as and when required' (PRN - pro re nata) medication would result in a more consistent approach being taken when medications were being administered. Organisation of staff personnel files would be beneficial in demonstrating a robust recruitment process. Annual appraisals for all staff were needed to ensure appropriate focus on continued staff development through practice and learning. The training matrix needed to be accurately maintained in order to demonstrate staff skills, knowledge and training needs. Quality assurance systems needed further development in order to clearly demonstrate the achievement of outcome-focussed actions that have resulted in improvements for residents. What the service has done since the last inspection There had been progress in the recording of people's possessions, inclusive of items of furniture. The recording of the interview process, including the decisions made, had improved. The records for the management of residents' monies that were held in the home had improved. Conclusion The manager and staff team were committed to providing a service that focused on ensuring residents received a good service that focused on their individual needs. There was a clear demonstration of commitment and motivation to ensure a service that continued to evolve and improve. page 4 of 31
1 About the service we inspected Inspection report Clashfarquhar House care home is a large house overlooking the centre of Stonehaven, Aberdeenshire. The service is owned and managed by Crossreach and provides service user accommodation and support for a maximum of 21 older people. At the time of our visit there was 18 residents accommodated. The home aims to support individuals in all they aspire to, in order that life is fulfilling and rewarding, in addition to offering an "individual needs led service to all within our care regardless of gender, culture, social background, or ability". This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April 2011. The Care Inspectorate regulates care services in Scotland. Information about all care services is available on our website at www.careinspectorate.com. 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. 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 page 5 of 31
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 5 - Very Good Quality of environment - N/A Quality of staffing - N/A Quality of management and leadership - Grade 4 - Good 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 www.careinspectorate.com or by calling us on 0345 600 9527 or visiting one of our offices. page 6 of 31
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 We undertook two unannounced inspection visits on 19 April 2016 between 10:00am and 4:00pm and on 27 April 2016 between 9:15am and 6:00pm. A further visit was made on 3 May 2016 when verbal feedback was given to the manager and deputy manager. On day one of the inspection visit we were accompanied by an inspection volunteer. Their feedback is recorded within the appropriate areas of this report. We took account of the completed annual return and self assessment forms that we asked the provider to complete and submit to us. The focus areas for this inspection were Care and Support and Management and Leadership. During this inspection process, we gathered evidence from various sources, including the following - residents' care documentation - a random number of MARs. - minutes of residents, relatives and staff meetings. - quality assurance records - staff training matrix - three staff files - Certificate of Registration. We spoke with: page 7 of 31
- fifteen residents - five relatives - the manager - the deputy manager - staff - one health professional - one volunteer. A general tour of communal areas of the home was also carried out as part of the inspection visit. We used the Short Observational Framework for Inspection (SOFI 2) to directly observe the experience and outcomes for people who were unable to tell us their views. On this occasion we observed one resident for a period of 40 minutes during the lunchtime meal. 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 page 8 of 31
apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at www.firescotland.gov.uk Inspection report page 9 of 31
The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self assessment document from the provider. We were satisfied with the way the provider completed this and with the relevant information included for each heading that we grade services under. The provider identified what it thought the service did well, some areas for development and any changes it had planned. The provider told us how the people who used the care service had taken part in the self assessment process. Taking the views of people using the care service into account People we spoke with told us: - "I am fine, I have no complaints. The staff are wonderful." - "I am well looked after, the staff are a good team. The food is good." - "It's all good. The food is fine." - "I am well looked after. I have no concerns." - "My lunch was lovely." page 10 of 31
As part of the inspection process we also sent Care Standards Questionnaires (CSQs) to 10 residents of which eight were returned. On review, additional comments recorded included: - "I like it here. The people here are very good." - "I am very happy here, the staff help me with everything I need. It is clean and tidy and staff help me get around the building." Taking carers' views into account People we spoke with told us: - "It is a very friendly, homely place. Staff are very supportive." - "My relative is very safe. The attention to detail is excellent. The review process is very helpful." As part of the inspection process we also sent CSQs to 10 relatives of which six were returned. On review, additional comments recorded included: - "Our only concern is when agency staff have to be employed during periods of staff shortage or illness. However, this happens infrequently and we believe the support staff are aware of possible difficulties." - "Delightful residential care home, gives me peace of mind that my relative is extremely well looked after in a very safe environment. Garden is not dementia friendly but plans are in place. Repairs could be carried out a little quicker to avoid anxiety of relative." - "Most staff have worked in Clashfarqhar for many years. This develops a 'homely' feeling which is obvious." - "If I thought there was a problem with my relative's care I know I would get all the help I needed." page 11 of 31
3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 5 - Very Good Statement 2 We enable service users to make individual choices and ensure that every service user can be supported to achieve their potential. Service strengths At this inspection we found the performance of the service for this statement to be very good. We reached this conclusion after we observed interactions between staff and residents and looked at a number of participation records. We also took into account the feedback from people, relatives and one professional who used the service. People's choice and preference were seen to be sought. We saw this demonstrated through review of care documentation and observation of practice. A person-centred approach to care had resulted in people being assisted in a way that took account of their individual needs and wishes. For example, what time they got up or went to bed, what they ate, what clothes they wore, and where they spent their time. People's privacy and dignity was respected. We saw this demonstrated through observation of staff practice. We saw that residents were assisted in a timely manner. Needs were seen to be met in a way that promoted independence and there was a continued focus on enabling people to be as active as possible. page 12 of 31
Communication between staff and residents was seen to be open and friendly. Conversations heard demonstrated a genuine interest in how residents were feeling. People were given the opportunity to take part in social activities and events. We saw that there continued to be a programme of activities being made available. This was resident led, with people being given a variety of resources and activities to choose from. There continued to be a focus on ensuring the programme available included activities that provided gentle exercise to help support people's physical needs. Links with the wider community continued and we saw residents being supported to attend local groups and areas of interest. People were kept informed of new developments and were encouraged to attend residents and relatives meetings. These provided an opportunity to actively participate in the decision-making processes. During our visit we were fortunate enough to be able to attend a meeting that focussed on the development of the garden area. This demonstrated an inclusive approach that captured people's opinions. Feedback from the inspection volunteer included: - "Clashfarquhar House is the former Bay Hotel in Stonehaven. It is an old building with a warren like room layout and spectacular views of the North Sea and Stonehaven bay and harbour." - "The residents I spoke to appeared to be generally very happy with the care provided to them." - "All of them looked well dressed, well nourished and attention had been paid to their personal appearance." People who used the service commented: - "I am notoriously happy here!" - "The food is very good." Inspection report page 13 of 31
- "I'm looked after very well." - "It's very nice here!" - "We have nothing but praise for the care provided here." - "There are plenty of activities available." - "I couldn't be better looked after." Quality of the environment: The care home is in an old building but is well maintained with a beautiful original wooden staircase. Bedrooms and common lounges were all odour free. All 18 residents had their own self contained flats rooms with en suite facilities and their own furniture. Quality of staffing: The residents and relatives were very complimentary about the staff and commented as follows: - "Very good staff." - "I'm very happy with the staff." - "Lovely people." - "The staff look after me very well." - "Very kind staff." - "Excellent staff." - "The staff showed a lot of empathy during our mother's illness." page 14 of 31
The staff observed appeared to be familiar with their charges and were attentive to their needs. Due to the installment of a new heating system a number of residents told us that the temperature of the home had increased and for some it was too hot. We shared this information with the manager who arranged for the facilities manager to visit and adjust the thermostat on the new boiler. We were assured that the situation would continue to be monitored to ensure residents' comfort was maintained. Areas for improvement In order to continue to provide an inclusive environment, there needed to be a continued focus on developing creative ways of seeking feedback from residents and their relatives/friends about the service they experienced. This was particularly important for those people who experienced difficulties in expressing themselves verbally. In discussion with the manager we talked about the use of dementia mapping skills to capture the quality of life outcomes experienced by residents who lived with a diagnosis of dementia. It was agreed that progress in this area of practice would be the focus of future inspection visits. Grade 5 - Very Good Number of requirements - 0 Number of recommendations - 0 Statement 3 We ensure that service users' health and wellbeing needs are met. page 15 of 31
Service strengths At this inspection we found the performance of the service for this statement to be very good. We reached this conclusion after we observed how residents were cared for and spoke with residents, relatives, staff, and one health professional. We also reviewed care documentation and associated records. People were being supported to maintain their health and social care needs. This was demonstrated in a number of ways, for example: - Recognised methods of assessment, risk assessment and care planning were used to support the health and social care of residents. On review of care documentation we saw that a person-centred approach had resulted in care plans that identified people's specific needs, wishes and preferences. There was a process of regular evaluation and review of how care was being delivered. We saw how residents and relatives had been included in the planning of how their needs were going to be met (see areas for improvement). - People's nutritional and hydration needs were being supported. We observed a mealtime and saw that people who needed assistance were given it in a way that encouraged their independence and promoted their dignity. People were offered a choice in what they ate and encouragement, gentle prompts and reassurance was given to those who needed it. For those more able, independence was encouraged by placing food serving dishes, tea/coffee, milk, and sugar on the table so that people could help themselves. - People were cared for by a staff team that demonstrated through discussion, and observation of practice, an understanding of people's needs. The manager had made us aware of an increase use of agency staff. However, it was confirmed that consistency had been achieved by accessing the same staff. The management of medication practices were reviewed. We saw that there were systems in place to demonstrate the safe receipt, storage and return of medications. Staff who had responsibility for the administration of medication had undertaken specific training to ensure they had the appropriate skills/ knowledge (see areas for improvement). page 16 of 31
People were protected from harm through staff awareness, training and knowledge of adult support and protection (ASP) policies and guidance. Inspection report During our visit we had the opportunity to speak with a health professional. They said that there was good communication with the staff team. They felt that staff were responsive to residents' needs and sought appropriate advice when needed. Staff demonstrated genuine warmth towards the residents and the atmosphere in the home was always welcoming. Areas for improvement In order to continue to ensure people's needs were being consistently identified and met there needed to be some further development of care plans and record keeping. This was because we saw that: - There were occasions when vague statements were being used such as "monitor closely" or "monitor regularly". These lacked clarity in how staff were to maintain people's health or welfare with a potential to impact on the continuity of care being provided. - There needed to be greater attention to the information recorded when respite care was being provided. This was to ensure that the same level of assessment and care planning was achieved regardless of the amount of time people used the service. This would ensure a consistent approach to keeping people well. - Care documentation was not always dated and signed by the person who wrote it. This made it difficult to demonstrate ownership and accountability of the entries. It also made it extremely difficult to determine if entries were still accurate and effectively evaluate the care being delivered. - A more formal assessment of a person's ability to manage their medication was needed. This would ensure a more risk-based approach to supporting their independence. - A more formal approach was needed to the evaluation of pain relief once administered. This was particularly important for analgesia administered as and page 17 of 31
when required. This would show the effectiveness of the medication and inform any medical review. - Completion of ABC behaviour charts needed to be more consistent and inform the plan of care more clearly. This would support staff to be consistent in the approach taken to support residents with more complex needs. (See Recommendation 1.) In order to ensure consistency in how medications were being managed there needed to be further development of the systems and processes in place. This was because when we looked at medication records we saw inconsistencies in practice as referenced below: - Handwritten entries on medication administration charts had not always been signed by two people. This would be needed to ensure accuracy of the information. - There needed to be clearer guidance around when PRN medication was to be administered. For example, when it was to be administered, at what point it would be administered and what measures would be taken to evaluate its effect. This would ensure greater consistency in practice. - Greater care was needed in the management of warfarin. This was because the information about what dosage to administer was not always clearly recorded once received from the healthcare team. Improvement in the above areas will be a focus of future inspection visits. Grade 5 - Very Good Number of requirements - 0 Inspection report page 18 of 31
Recommendations Number of recommendations - 1 1. It is recommended that all staff are made aware of the need to have consistency in how assessment, risk assessment and care planning is undertaken. Particular attention needs to be around those individuals who have more complex needs or have been admitted for respite care. This is to ensure care is effective and based on best practice. National Care Standards, Care Homes for Older People - Standard 6: Support Arrangements page 19 of 31
Quality Theme 2: Quality of environment Quality theme not assessed page 20 of 31
Quality Theme 3: Quality of staffing Quality theme not assessed page 21 of 31
Quality Theme 4: Quality of management and leadership Grade awarded for this theme: 4 - Good Statement 2 We involve our workforce in determining the direction and future objectives of the service. Service strengths At this inspection we found the performance of the service for this statement to be very good. We reached this conclusion after we spoke with staff and viewed minutes of team meetings. Staff spoken with described a supportive environment with the manager always having "an open door". They said that they were encouraged to develop their knowledge and skills. They confirmed that they felt part of a strong team that worked together in providing the best care to residents. They indicated that systems, such as team meetings and formal supervisions, allowed them to feel included in how the service was being managed and developed. Staff spoken with also told us: - "There is lots of support and information given." - "I have regular supervision and am encouraged to access training." - "It is a very supportive team, we have team meetings and we are asked for suggestions. I understand my role and responsibilities and have training to increase my knowledge." As part of the inspection process we sent CSQs to 10 members of staff of which five were returned. On review, additional comments included: page 22 of 31
- "I enjoy my work, I would like to get more training and build my qualifications up more." - "There are numerous training sessions for staff. I have been able to gain qualifications in supervisions and medication in the last year." Areas for improvement In order to continue the involvement of the staff team in the development of the service, we discussed with the manager the delegation of additional responsibilities, such as championship roles and the undertaking of some aspects of the quality assurance audits. Progress in this area will be a focus of future inspection visits. Grade 5 - Very Good Number of requirements - 0 Number of recommendations - 0 Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide. Service strengths At this inspection we found the performance of the service for this statement to be good. We reached this conclusion after we spoke with residents, relatives and staff. We also looked at quality assurance records. People were informed about what this service set out to provide. This was achieved by the accessibility of the Certificate of Registration and associated Staffing Schedule which were on display in the main entrance. Examples of other information clearly available to people included contact details for advocacy services, outcomes of quality assurance surveys, newsletters, the programme of activities, and comment slips. page 23 of 31
People were supported to raise concerns, queries or complaints. This was demonstrated through the accessibility of an appropriate complaints procedure. People we spoke with all confirmed that if they did have any issues they would feel able to speak with the manager and staff team at any time. Quality assurance was tested through the completion of a number of audits that were being used to assess the service being provided. Examples of these were care documentation, accident and incident, medication, and environment. Further development of these systems was being planned through the introduction of 'peer reviews' whereby the manager and senior staff would visit other services to undertaken reviews. Residents' monies were being managed appropriately. This was demonstrated on review of three records. We saw that improvements had been made in how transactions were being recorded. We saw that more frequent auditing had been started. Care was still needed to ensure any errors in the documentation were clearly explained to avoid confusion. As a result, the recommendation identified at the last inspection had been achieved. Feedback from the inspection volunteer included: - "The manager and her deputy had been there for a number of years and appeared to be very efficient." The manager was described as: - "A lovely lady." - "Very supportive." Inspection report Areas for improvement In order to demonstrate positive outcomes for residents and staff there needed to be greater consistency in demonstrating actions taken in response to quality assurance processes and audits. This was because when we viewed documentation and walked around the home we saw the following: page 24 of 31
- Staff appraisals had commenced but not been progressed. This had resulted in a number of staff not having the benefit of having the opportunity to discuss their practice and any development needs. - The staff training matrix had not been updated and therefore did not accurately reflect training completed, planned or where training had lapsed. - The staff toilet was used for storage of inappropriate items. This posed a potential risk of cross contamination. - An audit of eight care plans had been undertaken in March 2016 and we saw that, as a result, a large number of actions had been identified. There was no indication that these had been completed. - The medication audit had not identified the deficits as referenced in Quality Theme 1 - Statement 3 areas for improvement. - On review of audits we saw that there was inconsistency in the identification of timescales attached to actions. This would ensure the achievement of more measurable outcomes for residents. - We saw examples where actions had been identified with timescales, however, there was no indication if they had been achieved within the time period. At the last inspection we discussed with the manager how the development of an annual development plan would assist in a more structured and proactive approach being taken to the improvement of the service. This had not been progressed. As a result of the above, the recommendation identified at the last inspection remains in place (see Recommendation 1). Grade 4 - Good Number of requirements - 0 Inspection report page 25 of 31
Recommendations Number of recommendations - 1 1. It is recommended that a more formal approach is taken to the implementation of quality assurance systems and processes in line with the provider's own guidance. National Care Standards, Care Homes for Older People - Standard 5: Management and Staffing Arrangements 4 What the service has done to meet any requirements we made at our last inspection Previous requirements 1. The provider must develop and introduce a system for assessing the safety and suitability of furnishings and equipment brought into the home by service users. This is in order to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011, (SSI 2011/210) Regulation 4(1) - regulations relating to the welfare and safety of service users. Timescale: within six weeks of receipt of this report. This requirement was made on 28 May 2015 The manager was able to demonstrate the documentation being used to record a list of items being brought into the home. We saw this being put into practice when we viewed a number of people's care files. We were also aware that specific reference page 26 of 31
had been made in the service's brochure about the importance of ensuring items of furniture or furnishings had fire retardant properties. Met - Outwith Timescales 5 What the service has done to meet any recommendations we made at our last inspection Previous recommendations 1. It is recommended that a more consistent approach is taken to the management of residents' monies to ensure best practice is maintained in ensuring people are protected from potential financial abuse. National Care Standards, Care Homes for Older People - Standard 5: Management and Staffing Arrangements This recommendation was made on 28 May 2015 Please see the main body of this report for more information. 2. It is recommended that a more formal approach is taken to recording the discussions and outcomes of interviews. This, along with the implementation of a process to verify references, would strength the decision-making process. National Care Standards, Care Homes for Older People - Standard 5: Management and Staffing Arrangements This recommendation was made on 28 May 2015 page 27 of 31
A review of four staff files demonstrated progress in the information recorded during the interview process. We saw that information recorded captured the discussions and outcome of interviews. As a result this recommendation has been achieved. 3. It is recommended that a more formal approach is taken to the implementation of quality assurance systems and processes in line with the provider's own guidance. National Care Standards, Care Homes for Older People - Standard 5: Management and Staffing Arrangements Inspection report This recommendation was made on 28 May 2015 Please see the main body of this report for more information. 6 Complaints No complaints have been upheld, or partially upheld, since the last inspection. 7 Enforcements We have taken no enforcement action against this care service since the last inspection. 8 Additional Information There is no additional information. page 28 of 31
9 Inspection and grading history Inspection report Date Type Gradings 20 Apr 2015 Unannounced Care and support 5 - Very Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 10 Jun 2014 Unannounced Care and support 5 - Very Good Environment 4 - Good Staffing 5 - Very Good Management and Leadership 4 - Good 24 May 2013 Unannounced Care and support 5 - Very Good Environment 4 - Good Staffing 5 - Very Good Management and Leadership 4 - Good 13 Aug 2012 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 1 Jul 2011 Unannounced Care and support 4 - Good Environment Not Assessed Staffing Not Assessed Management and Leadership 4 - Good 27 Oct 2010 Unannounced Care and support 4 - Good Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed 27 May 2010 Announced Care and support 4 - Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed page 29 of 31
10 Nov 2009 Unannounced Care and support 4 - Good Environment 4 - Good Staffing Not Assessed Management and Leadership Not Assessed Inspection report 18 May 2009 Announced Care and support 4 - Good Environment 4 - Good Staffing 5 - Very Good Management and Leadership 4 - Good 29 Oct 2008 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 23 Apr 2008 Announced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good page 30 of 31
To find out more This inspection report is published by the Care Inspectorate. You can download this report and others from our website. You can also read more about our work online. Contact Us Care Inspectorate Compass House 11 Riverside Drive Dundee DD1 4NY enquiries@careinspectorate.com 0345 600 9527 www.careinspectorate.com @careinspect Other languages and formats This report is available in other languages and formats on request. Inspection report Tha am foillseachadh seo ri fhaighinn ann an cruthannan is c?nain eile ma nithear iarrtas. page 31 of 31