St Serfs
Care Home Service Adults
Kinbrae Park Gardens
Newport-on-Tay
DD6 8HD
Inspected by: Beth Martin
Type of inspection: Unannounced
Inspection completed on: 17 September 2012
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Contents
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Summary
About the service we inspected
How we inspected this service
The inspection
Other information
Summary of grades
Inspection and grading history
Service provided by:
St. Serfs Care Home Ltd
Service provider number:
SP2010010981
Care service number:
CS2010251669
Contact details for the inspector who inspected this service:
Beth Martin
Telephone 01383 841100
Email [email protected]
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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
There is a group of volunteers called the Silver Liners which consists of relatives and
members of the local community. The Silver Liners attend the home every Monday for
poetry and every Thursday to escort residents on outings such as going to the local
cafe. They also attend to support residents to take part in Tai Chi every Tuesday. The
group keeps records of the activities and the participants.
What the service could do better
One recommendation has been made during this inspection regarding training in a
specific area. This has been reported on under Quality theme 3- statement 3; Quality
of Staffing.
What the service has done since the last inspection
One requirement was made during the previous inspection regarding the Manager
requiring to be supernumerary 100% of her time. This requirement has been met.
Conclusion
Residents and visitors to the home spoken with on the day of the inspection
highlighted their satisfaction with the service. All stated that they felt comfortable
approaching all the staff and knew that any concerns would be dealt with. During the
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inspection, staff were observed to be interacting with the residents in a dignified and
respectful manner.
Who did this inspection
Beth Martin
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1 About the service we inspected
The Care Inspectorate regulates care services in Scotland. Prior to 1 April 2011, this
function was carried out by the Care Commission. Information in relation to all care
services is available on our website at www.careinspectorate.com.
The Care Inspectorate will award grades for services based on findings of inspections.
Grades for this service may change after this inspection if we have to take
enforcement action to make the service improve, or if we uphold or partially uphold a
complaint that we investigate.
The history of grades which services have been awarded is available on our website.
You can find the most up-to-date grades for this service by visiting our website, by
calling us on 0845 600 9527 or visiting one of our offices.
Requirements and recommendations
If we are concerned about some aspect of a service, or think it could do more to
improve its service, we may make a recommendation or requirement.
- A recommendation is a statement that sets out actions the care service provider
should take to improve or develop the quality of the service but where failure to do so
will not directly result in enforcement.
- A requirement is a statement which sets out what is required of a care service to
comply with the Public Services Reforms (Scotland) Act 2010 and Regulations or
Orders made under the Act, or a condition of registration. Where there are breaches of
the Regulations, Orders or conditions, a requirement must be made. Requirements are
legally enforceable at the discretion of the Inspectorate.
St Serfs home consists of a large Victorian house with a more modern extension
added. The home was owned by the Scottish Episcopal Church until May 2010 when it
was sold to a private company headed by Mr and Mrs Thain.
St Serfs is set in its own spacious grounds, close to the River Tay and is registered to
provide care and support to a maximum of 26 older people. The main house has been
refurbished and upgraded in recent years. The gardens are well maintained with a
summer house and seating areas for residents' use.
The home has two double occupancy rooms but all rooms are used as single
occupancy rooms unless specifically requested by two people with an established
relationship. All rooms have en-suite toilet facilities.
The Acting Care Home Manager is responsible for the day to day running of the home
and the supervision of staff. She was present on the second day of the inspection and
received the inspection feedback. The Provider was present throughout the
inspection.
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The home's Philosophy of Care states:
"To provide a secure, stable and comfortable environment whilst providing a standard
of individual mental and physical care ensuring that each resident is as happy and
contented as possible.
To ensure that the dignity of each resident is maintained at all times.
To stimulate and maintain physical and mental activities by setting realistic targets
and encouraging residents to participate in the decision making in an attempt to
reach these targets.
To enhance the quality of life by providing a safe, secure, comfortable and supportive
environment.
To ensure each resident's right to personal choice especially in relation to clothes, diet
and activities.
To encourage residents to care for themselves where they are willing and able, and to
regularly update care plans to take account of this.
To ensure that each resident is treated as an individual and that others respect his or
her dignity irrespective of any disability or frailty.
To maintain each resident's right to privacy by ensuring all staff knock before entering
a room.
To maintain each resident's right to be consulted in any proposed changes to daily
living arrangements and to encourage their participation in making suggestions and
decision making.
To maintain each resident's right of choice of family Practitioner, Dentist, Optician,
Chiropodist etc. where possible.
To ensure each resident has the right to socialise with the community at large by
encouraging them to invite family, friends and acquaintances into our care home.
To maintain each resident's right to have their political, religious, sexual beliefs and
emotional needs accepted and respected.
Based on the findings of this inspection this service has been awarded the following
grades:
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Quality of Care and Support - Grade 4 - Good
Quality of Environment - Grade 4 - Good
Quality of Staffing - Grade 4 - Good
Quality of Management and Leadership - Grade 4 - Good
This report and grades represent our assessment of the quality of the areas of
performance which were examined during this inspection.
Grades for this care service may change following other regulatory activity. You can
find the most up-to-date grades for this service by visiting our website
www.careinspectorate.com or by calling us on 0845 600 9527 or visiting one of our
offices.
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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
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.
As requested by us, the provider sent us an annual return. The provider also sent us a
self assessment form.
This report is based on an unannounced inspection at St Serfs Care Home which took
place on 7th and 17th September 2012. Feedback on the outcome of the inspection
was given to the Acting Care Home Manager and the Provider on the second day of
the inspection. The inspection was carried out by Beth Martin Inspector.
During the inspection, evidence was gathered from a number of sources including:
• Talking with residents and visitors to the home
• Discussion with the Provider, Acting Care Home Manager and staff.
• Examination of a sample of the policies, procedures, health & safety records
which the service is required to maintain.
• Review of a sample of residents personal care files to check how staff assess
needs and how these are met.
• Accident and incident records.
• Minutes of meetings.
• Staff training records.
• Check of the building and environment to make sure it is well maintained,
safe and free from hazards.
• Observation of staff practices.
Questionnaires were supplied for residents and relatives/visitors to the home: 17 were
returned to the Care Inspectorate prior to the inspection.
All of the above information was taken into account during the inspection process
and was reported on.
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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 service, so they may consider what action to
take. You can find out more about care services' responsibilities for fire safety at
www.firelawscotland.org.
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
www.firelawscotland.org
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What the service has done to meet any requirements we made at
our last inspection
The requirement
A Provider shall, having regard to the size and nature of the service, the statement of
aims and objectives and the number and needs of the service user: ensure that at all
times suitably qualified and competent persons are working in the care service in
such numbers as are appropriate for the health and welfare of service users. This is in
order to comply with The Social Care and Social Work Improvement Scotland
(Registration) Regulations 2011 (SSI 2011/210), regulation 15.
What the service did to meet the requirement
The staffing schedule which is a condition of registration with SCSWIS states that the
Manager or person in charge should be supernumerary 100% of their working hours.
It transpired during the previous inspection that in the absence of the Manager e.g.
annual leave the person in charge was not supernumerary. This was in breach of a
condition of registration therefore a requirement was made. The service submitted an
action plan which stated that from 08.08.2011 this practice would change and the
person in charge would be supernumerary 100% of their working hours. It was
verified during this inspection that this had been adhered to.
The requirement is: Met
The annual return
Every year all care services must complete an 'annual return' form to make sure the
information we hold is up to date. We also use annual returns to decide how we will
inspect the service.
Annual Return Received: Yes - Electronic
Comments on Self Assessment
Every year all care services must complete a 'self assessment' form telling us how
their service is performing. We check to make sure this assessment is accurate.
The Care Inspectorate received a fully completed self assessment document from the
service provider. We were satisfied with the way the service provider had completed
this and with the relevant information they had given us for each heading that we
grade them under.
The service provider identified what they thought they did well, some areas for
development and any changes they had planned.
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Taking the views of people using the care service into account
The Inspector observed daily practice during the inspection and
spoke with residents. Comments and opinions offered by residents were very positive
and have been included in the body of this report.
Taking carers' views into account
The Inspector spoke with visitors to the home on the day of the inspection. Their
comments are addressed within the body of this report.
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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
Resident meetings are held three monthly to gain their views on service planning and
delivery. During one of the meetings they requested new plants for the planters. The
residents chose the plants and were supported to plant and nurture them. The
volunteers take the residents on seasonal walks around the garden to see how they
are doing and decide what else they need. The residents also asked to keep chickens;
the volunteers are actioning this and on the day of the inspection they were trying to
source a chicken coop.
The residents had shown interest in a yogurt maker. The Cook sourced one which the
Provider purchased and the residents have all had the opportunity to go into the
kitchen and see how it is made; they now have freshly made yogurt every day. They
also suggested having soup and sandwiches as an option at tea time as they have a
three course lunch; this has been added to the menu. Some residents felt they were
getting their breakfast either too early or too late. Each resident was then asked what
time they would prefer and the breakfasts are now delivered to their bedrooms at the
allotted time. They also have the option to have breakfast in the dining room. Another
suggestion was to have the person in charge of each shift clearly identified; this is
now at the front door. Tai Chi is now offered to residents on a weekly basis at their
request.
One area for improvement highlighted by the service last year was to get skype. This
is now in place and one resident is now in regular contact with her daughter in South
Africa.
During the relatives' meetings it was highlighted that they wanted new carpets
throughout the house. The carpet in the extension corridor is being replaced which
has been chosen by the residents. The carpet in the main house was professionally
cleaned and is scheduled to be replaced as part of the refurbishment programme.
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The Providers attend the relative meetings and were informed during one of the
meetings that visitors to the home didn't want to see the bins outside from the
driveway up to the home. The Inspector was informed that an enclosure is going to
be built around the bins to combat this. There was also furniture outside waiting to
be uplifted by the Council which the relatives found unsightly. The Provider arranged
for this to be uplifted by other means.
The back door has an exit key pad attached. The Provider wanted to make the home
more secure as the door had been left open on occasion. The relatives were consulted
with who stated that they still wanted access. As a compromise the code has been
changed and only given out to resident's next of kin. The minutes of relatives
meetings are e-mailed to those who wish it.
Staff meetings are held three monthly but the Inspector was informed during the
inspection that this will be changed to monthly when the new Manager is recruited.
During one of their meetings the staff highlighted the need for a fourth member of
staff on the late shift to support the residents. The Provider held a meeting with the
relatives and their request was granted. Staff had also expressed their dissatisfaction
with the amount of time they had to spend assisting with laundry duties; a Laundry
Assistant has since been employed.
Questionnaires are not a regular occurrence in the home however one was given to
the residents in May of this year. They were asked if there was anything they didn't
like about their room. 11 residents replied yes. The Manager spoke with every resident
to ascertain the issues. All issues were minor such as bulbs out in lamps etc and all
were dealt with.
One of the resident's relatives produces a newsletter every quarter with the support
of the residents and staff. The newsletter contains information such as:
activities
forthcoming events
welcoming new residents
celebrating the lives of those residents who are no longer with them
staff news and training.
The service has a suggestion box in the front foyer. The Inspector was informed
during the inspection that the service is planning on starting a 'wish list' for each
resident. The residents will advise staff of things they wished they could do and the
staff will support them to achieve this. The Inspector was informed that one of the
resident's relatives is very interested and knowledgeable in family history. The service
is planning a 'This is Your Life' or 'Who Do You Think You Are' event as their winter
project. The intention is to enhance staff and resident's knowledge about each other.
Comments received from residents during the inspection included:
"Oh we are well looked after"
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"They help us in any way they can"
"I've no complaints with the food"
"I like my own bedroom; I have my own stuff in it"
"I like it I must say"
"I've been here a long time; I'm quite comfortable"
"It's lovely, it's very very good"
"I have no complaints"
"The food is very good; the Cook is very good".
Comments received from relatives during the inspection included:
"My Mother is very happy in St Serfs Care Home and well looked after"
"I would like to know the ratio of staff to number of residents in care as I feel the
excellent staff employed are often stretched to the limit and this then effects the
entertainment and social events"
This issue has hopefully been resolved since the increase of staff as discussed above.
Other comments received were regarding staffing, the carpets and the laundry. The
Inspector was informed that these issues have now also been resolved as described
above.
Areas for improvement
Consideration could be given to ascertaining the Service User's wishes regarding
going on holidays.
Although action was taken following the resident questionnaire, there was no formal
collation or action plan devised. It would be good practice to do this as it would
produce a record of outcomes and improvements made.
Consideration could be given to devising alternative methods of enabling Service
Users and relatives to participate in assessing and improving service planning and
delivery.
Grade awarded for this statement: 4 - Good
Number of requirements: 0
Number of recommendations: 0
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Statement 3
We ensure that service users' health and wellbeing needs are met.
Service strengths
Every resident is registered with the local G.P. who holds a clinic in the home every
week. A private Chiropodist visits the home three monthly or as required and those
residents suffering from Diabetes and other specific ailments have regular visits from
the NHS Podiatrist. Residents have an annual optical check up carried out by a
Glasgow based company and the Dietician visits the home if required. Residents have
the option to remain with their own Dentist after admission or access the NHS
Dentist as required; a local Dentist will also attend the home if necessary. The home
has good relationships with the Community Psychiatric Nurses via the Consultant and
Macmillan Nurses, Occupational Therapists, Speech and Language Therapists
(SALT) and Physiotherapists are all accessible via the G.P. The Consultant holds a clinic
at one of the local surgeries and will visit the home if required. The District
Nurse attends the home on an as required basis according to the needs of the
residents. The Hairdresser attends the home every week and the Beautician attends
every fortnight..
Every resident has a care plan which is devised in collaboration with the resident and
their family and is signed by both parties on admission. Care plans are reviewed
monthly by the Key Workers and six monthly reviews take place whereupon families
are invited to attend. Social Work reviews are held on an annual basis and again
families are invited to attend. The monthly reviews are comprehensive and include a
one to one meeting with the resident and their Key Worker.
The service is in the process of recruiting a full time Activities Co-ordinator. At present
most residents have a life story outlining their social interests (some families have not
completed these yet). There is monthly activity planner devised by the Deputy
Manager which includes activities such as:
carpet bowls
Chapel Services
bingo
bounce the ball
sing- a- long
quizzes.
The Inspector was informed that the activity planner is only a guide as the residents
choose the daily itinerary for each day. The residents enjoy the external entertainment
which is provided every two weeks and they had also enjoyed a trip to Cairnie Maze in
the Summer. There is a group of volunteers called the Silver Liners which consists of
relatives and members of the local community. The Silver Liners attend the home
every Monday for poetry and every Thursday to escort residents on outings such as
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going to the local cafe. They also attend to support residents to take part in Tai Chi
every Tuesday. The group keeps records of the activities and the participants.
The residents celebrate seasonal events such as the forthcoming Harvest Festival and
world wide events such as the Jubilee and the Olympics. The residents were looking
forward to a visit from Owls & Co (owls from a Blairgowrie based company) on the
day following the inspection. The Scottish Ensemble String Orchestra had also been
booked to entertain the residents.
Areas for improvement
Residents are weighed on a monthly basis to monitor any fluctuations; record sheets
are kept. However the record sheets dictate that weights should be carried out
weekly. Although the task is being carried out in accordance with the home's
procedures the guidance on the recording sheets should reflect this.
In one instance a resident had a pain assessment diagram highlighting that he
suffered from pain in his toes. Although the staff spoken with were aware of this, the
pain assessment sheet was blank therefore there was no explanation of the cause,
diagnosis or treatment of pain in that section of the care plan. The Provider stated
that care plans are to be given priority when the new Manager is appointed.
When the Activities Co-ordinator is appointed priority should be given to improving
the activities assessments (some of which were blank) and records to evidence that
activities offered are meaningful to the individual. A long discussion took place with
the Provider regarding this during the inspection. At present the Care Home staff do
not keep records of activities undertaken. Records should be kept of the activity,
resident participation and their level of ability and enjoyment. This enables the service
to plan and offer future activities suited to the individual.
It was noted that although the Silver Liners offer the opportunity to take the residents
out locally once a week, numbers are limited. Consideration should be given to
offering residents the opportunity to go on more outings of their choice.
Comments received from residents during the inspection included:
"If we're not well they tend to us"
"They get the Doctor if we need it"
"They look after my health well. They make sure I get my medication every morning"
"They're very caring"
"You only have to sneeze in here and they ask if you need a Doctor".
Grade awarded for this statement: 4 - Good
Number of requirements: 0
Number of recommendations: 0
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Quality Theme 2: Quality of Environment
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 environment within the service.
Service strengths
The evidence for the grade awarded in this statement is included in Theme 1,
Statement 1- Service Strengths above.
Areas for improvement
The areas for development for this statement are included in Theme 1, Statement 1Areas for Improvement above.
Grade awarded for this statement: 4 - Good
Number of requirements: 0
Number of recommendations: 0
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Statement 2
We make sure that the environment is safe and service users are protected.
Service strengths
The service has an Adult Protection Policy, a Child Protection Policy, a recruitment
policy and a complaints policy in place. Staff are requested to read and sign to
confirm that they have understood the document.
The front door is locked at all times and the back door has an exit key pad attached.
Risk assessments are carried out for both inside and outside the premises on an
annual basis by an external contractor. Health & Safety checks are carried out by staff
on a daily basis These include ensuring fire exits are free from obstruction.
An electrical contractor checks the fire alarm system, emergency lighting, sensors and
equipment every six months and the Fire Officers carry out an annual safety
check. Another contractor is responsible for maintaining the Nurse call system
although they are checked by staff weekly. Hoists, baths and lifts are maintained
regularly by contractors as are the water temperatures/systems.
The Cook is responsible for carrying out weekly kitchen audits. Audit records are kept
and were seen to be up to date.
Accident and incident records are maintained and monitored to highlight any
particular patterns and put procedures into place to prevent recurrence.
Safe recruitment practices were evident for the protection of residents. The service
had received one complaint since the previous inspection which was dealt with
appropriately.
One comment received from a resident during the inspection was:
"I feel safe".
One comment received from a relative during the inspection was:
"I have nothing but praise for St Serfs. My relative is happy and contented and feels
safe and secure. She loves the food. Only minor preference would be for a detailed
account given of the petty cash kept for each resident and this communicated to the
family e.g. sent out annually".
This comment was discussed with the Provider during the inspection and the matter
had already been resolved.
Areas for improvement
The Inspector was informed that the staff carry out regular checks on residents'
wheelchairs and bed rails to ensure they are fit for purpose. Consideration could be
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given to keeping a record of these to ensure the checks are carried out and to provide
an audit trail.
Grade awarded for this statement: 4 - Good
Number of requirements: 0
Number of recommendations: 0
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Quality Theme 3: Quality of Staffing
Grade awarded for this theme: 4 - Good
Statement 1
We ensure that service users and carers participate in assessing and improving the
quality of staffing in the service.
Service Strengths
The evidence for the grade awarded in this statement is included in Theme 1,
Statement 1- Service Strengths above.
Areas for improvement
The areas for development for this statement are included in Theme 1, Statement 1Areas for Improvement above.
Grade awarded for this statement: 4 - Good
Number of requirements: 0
Number of recommendations: 0
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Statement 3
We have a professional, trained and motivated workforce which operates to National
Care Standards, legislation and best practice.
Service strengths
New staff members have a three day induction period when they are supernumerary.
They receive a staff handbook which outlines 'rights, regulations and responsibilities'.
They also receive a workbook which they have to complete within one month of
commencing employment. The workbook covers topics such as First Aid, Infection
Prevention & Control, The Principles of Care, Fire Safety, Health & Safety and
Communication.
The services annual mandatory plan consists of:
Fire Safety - delivered by an external company
Moving & Handling - delivered by an external company
Medication Training - delivered by Boots the Chemist
Control of Substances Hazardous to Health (COSHH)
The Provider stated that she is adding Dementia Training - Tomorrow is Another Day;
Alzheimers Scotland for which she is a Trainer to the mandatory training.
In house training since the previous inspection includes:
Drug Training
Action on Hearing Loss
DAPL (Drug Alcohol Project Ltd)
Monthly Reviews & Outcomes for Care Plans
Continence Advisory & Treatment Service
MUST (Malnutrition Universal Screening Tool) Training.
The Acting Manager is responsible for highlighting training needs and making the
annual training plan. The Provider stated that the plan can change at any time
depending on the needs of the residents. The Inspector was informed that the service
takes advantage of NHS training on offer. The Office Manager maintains the training
records and all staff are requested to complete an evaluation sheet after each training
session.
Staff receive supervision bi-monthly and the Inspector was informed that all staff will
have received an annual appraisal by the end of 2012. The annual appraisal will
include a personal development plan. During staff supervision some staff had
requested Dementia training due to the needs of the residents. The Provider has
added this to the annual mandatory training which will be delivered in October. In the
meantime she has given each member of staff an information pack concentrating on
reality orientation and managing residents who tend to wander. The Inspector was
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informed that staff have stated they now feel more confident dealing with these
issues.
On the day of the inspection one member of staff had attained an SVQ level II
certificate and one member of staff was undertaking the training. Three members of
staff had attained an SVQ level III certificate and seven members of staff were
undertaking the training. The Acting Manager held an SVQ level III certificate in Health
and Social Care.
Comments received from residents during the inspection included:
"I've never regretted it the staff are excellent"
"They're very caring".
Areas for improvement
Although staff receive Infection Control training during induction they should receive
an annual update. The Provider stated that this had been an oversight and she will
ensure the training is delivered before the end of the year. A recommendation (1) is
made.
Grade awarded for this statement: 4 - Good
Number of requirements: 0
Number of recommendations: 1
Recommendations
1. It is recommended that Infection Control training is delivered to all staff who have
not received it within the past 12 months.
National Care Standards - Care Homes for Older People: Standard 5.1, 5.2 and 5.4
have been taken into account whilst making this recommendation.
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Quality Theme 4: Quality of Management and Leadership
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 management and leadership of the service.
Service strengths
The evidence for the grade awarded in this statement is included in Theme 1,
Statement 1- Service Strengths above.
Areas for improvement
The areas for development for this statement are included in Theme 1 Statement 1Areas for Improvement.
Grade awarded for this statement: 4 - Good
Number of requirements: 0
Number of recommendations: 0
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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
There are quality audits in place to ensure organisational policies and procedures are
being adhered to. The Manager sends an audit report to the service Provider on a
weekly basis which includes information on:
Accidents & Incidents
Staff absence and turnover
Annual leave
Recruitment needs
Staff meeting agendas
Training needs & suggestions
Occupancy, admissions, discharges and enquiries
Maintenance needs
Hazards and health & safety
Complaints.
Fire safety checks are carried out weekly and audited by the Acting Manager every
month; mock evacuations take place twice per year. Medication storage and
recording is audited by the Senior Carers monthly; the Acting Manager carries out
random checks and Boots the Chemist attends the home every six months for a full
review. Controlled drugs are checked by two members of staff each time medication
is administered; The Acting Manager audits this weekly. It is the responsibility of the
Key workers to ensure resident's care plans are kept up to date; the Acting Manager
carries out random audits. All kitchen checks are carried out daily by the Cook and
Kitchen Assistant and audited by the Acting Manager weekly. The service employs a
Handyman who will attend the home when required.
The Acting Manager operates an 'open door' policy for residents, staff and relatives
and it was obvious during the days of inspection that she knew the residents and
relatives very well. All visitors appeared comfortable during conversations with the
Acting Manager and staff.
The Acting Manager was aware of the SSSC (Scottish Social Services Council) Codes of
Practice and her responsibility to report to the SSSC and the Care Inspectorate any
dismissal on the grounds of misconduct including theft. The Provider was aware of
her obligation to comply with the timescales of the SSSC registration of Care Staff.
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Areas for improvement
The service highlighted in the self assessment document it's intention to continue
with regular meetings with the owners and residents and families as this is very
productive and helps to ensure clear channels of communication.
Grade awarded for this statement: 4 - Good
Number of requirements: 0
Number of recommendations: 0
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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
On the day of the inspection the following documents were on display in the care
home:
A valid insurance certificate verifying liability insurance cover.
A staffing schedule agreed with the Care Commission as a condition of registration.
A valid registration certificate.
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).
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5 Summary of grades
Quality of Care and Support - 4 - Good
Statement 1
4 - Good
Statement 3
4 - Good
Quality of Environment - 4 - Good
Statement 1
4 - Good
Statement 2
4 - Good
Quality of Staffing - 4 - Good
Statement 1
4 - Good
Statement 3
4 - Good
Quality of Management and Leadership - 4 - Good
Statement 1
4 - Good
Statement 4
4 - Good
6 Inspection and grading history
Date
Type
Gradings
7 Jul 2011
Unannounced
Care and support
Environment
Staffing
Management and Leadership
4 - Good
Not Assessed
Not Assessed
4 - Good
9 Dec 2010
Unannounced
Care and support
Environment
Staffing
Management and Leadership
4 - Good
Not Assessed
4 - Good
Not Assessed
13 Sep 2010
Announced
Care and support
Environment
Staffing
Management and Leadership
4 - Good
Not Assessed
3 - Adequate
Not Assessed
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All inspections and grades before 1 April 2011 are those reported by the former
regulator of care services, the Care Commission.
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To find out more about our inspections and inspection reports
Read our leaflet 'How we inspect'. You can download it from our website or ask us to
send you a copy by telephoning us on 0845 600 9527.
This inspection report is published by the Care Inspectorate. You can get more copies
of this report and others by downloading it from our website:
www.careinspectorate.com or by telephoning 0845 600 9527.
Translations and alternative formats
This inspection report is available in other languages and formats on request.
Telephone: 0845 600 9527
Email: [email protected]
Web: www.careinspectorate.com
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