Springburn House Care Home Service Adults 62 Broomfield Rd G21 3UB Telephone: 0141 2761810

Inspected by: Kathy Godfrey Marjorie Bain Type of inspection: Unannounced Inspection completed on: 31 October 2013 Inspection report continued

Contents

Page No Summary 3 1 About the service we inspected 6 2 How we inspected this service 7 3 The inspection 11 4 Other information 29 5 Summary of grades 30 6 Inspection and grading history 30

Service provided by:

Service provider number: SP2003003390

Care service number: CS2003001040

Contact details for the inspector who inspected this service: Kathy Godfrey Telephone 0141 843 6840 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 Personal plans have good information including a detailed life history. There are detailed routines for getting up in the morning and personal care.

Residents have lots of opportunities to participate in the home such as six monthly reviews of their service, residents meetings and questionnaires. They were encouraged to choose colours for a recent refurbishment.

The home will be closing soon with residents moving to purpose built premises. The home have kept everyone up to date with the progress of this and arranged visits to the bedroom "mock up" for residents and relatives.

Staff are very knowledgeable about residents especially health needs. They have a good induction and access to further training through an e-learning programme.

What the service could do better There should be a clear trail of evidence to show how any complaints are investigated.

A recommendation at the previous inspection identified that the MUST tool was not used consistently to monitor residents nutritional risks. As a result of the daily fluid and dietary intake charts not always being filled in this ecor mmendation is repeated.

Springburn House, page 3 of 32 Inspection report continued We found poor use of ABC charts for people whose behaviour could at times be challenging. Where charts did exist they were generally either incomplete, some had gone missing or lacked appropriate detail. We advised that staff should be retrained in the use of ABC charts.

There was a lack of stimulating, meaningful activities. We observed that due to the lay out of the building and the care duties staff need to do there are not enough staff to offer a stimulating environment. We feel staffing levels need to be further reviewed.

We observed that most of the toilets did not have a bin with a lid. This is an infection control issue as all toilets should have a bin with a lid.

The provider must meet their responsibility to submit relevant notifications to the Care Inspectorate.

The manager should establish a system of recording contact with residents and visiting relatives.

We noted the manager had issued a questionnaire to staff seeking feedback about the quality of supervision, management and general support for staff. Although these had been returned there was no evidence of an action plan to deal with any issues raised.

What the service has done since the last inspection Personal plans now detailed how the home intended to meet new residents health, welfare and safety needs within 28 days of starting the service.

The servery area had been refurbished to a good standard.

There was now an extra "floating" staff member on each early and late shift to help out in the units.

Conclusion The service have good personal plans with detailed life histories. There are lots of ways for residents to participate in the service. Staff are very knowledgeable about the support needs of the residents.

There should be a stimulating, meaningful activities programme. The provider should review staffing levels to enable staff to deliver a stimulating environment.

Springburn House, page 4 of 32 Inspection report continued Who did this inspection Kathy Godfrey Marjorie Bain

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1 About the service we inspected

The Care Inspectorate regulates care services in . It awards grades for services based on the findings of inspections. These grades, including any that services were previously awarded by the Care Commission, are available on www.careinspectorate.com

Springburn House is registered as a care home to provide support to a maximum of 46 older people. At the time of the inspection visit, the service was provided to 37 adults who required support due to needs associated with frailty and/or dementia.

The home is located within a residential area in the Springburn area of Glasgow. The service is managed by Glasgow City Council.

The accommodation comprised of two floors with two units on each floor. Each unit has their own dining room and lounge area. Bedrooms were provided on a single occupancy basis with wash-hand basin. Shared bathing and toilet facilities were available in each of the units. A small garden area is available at the front of the home.

Before 1 April 2011, this service was registered with the Care Commission. On this date the new scrutiny body Social Care and Social Work Improvement Scotland (the Care Inspectorate), took over the work of the Care Commission, including the registration of care services. This means that from 1 April 2011 this service continued its registration under the new body, the Care Inspectorate.

Based on the findings of this inspection this service has been awarded the following grades:

Quality of Care and Support - Grade 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 We wrote the report following an unannounced inspection. The inspection was carried out by Kathy Godfrey and Marjorie Bain over 2 days the 30th and 31st of October 2013. In this inspection we gathered evidence from various sources, including the relevant sections of policies, procedures, records and other documents including:

Certificate of Registration Accident log Incident log Complaints/suggestions log Medication records Quality Assurance Audits Questionnaires Resident meeting minutes Carer meeting minutes Personal plans Staff training records Staff meeting minutes Staff supervision notes Self assessment document Newsletter We met with the manager, four senior care workers and three care workers. We spoke with 19 residents and three visiting relatives or friends. We gave feedback to the manager of the service on 31st October.

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.

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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 The service provider must ensure that service users' personal plans set out how the health, welfare and safety needs of the individual are to be met within 28 days of the date they first eceivr e the service.This is to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI2011/210), Regulations 5(1)Timescale - Within 1 week of publication of this report, the provider must meet this requirement.

What the service did to meet the requirement We looked at personal plans and could see that this had been carried out

The requirement is: Met - Within Timescales

What the service has done to meet any recommendations we made at our last inspection The service should ensure that there is consistent use of the MUST to monitor residents nutritional risk and their progress. We looked at health and nutrition care plans. Although there had been an improvement in the use of MUST there were still gaps where staff had not filled them in. This recommendation is therefore repeated. (see Recommendation 1, under Quality Theme 1, statement 3)

The provider should continue with the refurbishment programme of server areas to ensure that they are improved and are of a standard appropriate for a food storage and preparation area. We looked at the server area and could see the work had been completed to a good standard

The provider should inform the Care Inspectorate of the outcome of the review of staffing levels. The home now had an extra "floating " staff member. However we feel that due to the layout of the building and the care needs of residents there should be a further review of staffing levels. (see Recommendation 1, under Quality Theme 4, statement 4)

Springburn House, page 9 of 32 Inspection report continued 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. We 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 of the headings that we grade them under.

The service provider identified what they thought they did well, some areas for development and any changes they planned. The service 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 We spoke with 19 residents over the two days we were there. Residents we spoke with were all generally happy with the service. Some of the comments they told us were: "I like living here" "food is good" "I like the food" "I'm happy here" "sometimes not enough to do" "would like more outings" "decoration is lovely" "no complaints" I have no complaints"

Taking carers' views into account We spoke with three visiting relatives and friends. There were all happy with the service their friend or family member received. One commented "my relative seems very happy here. I have no concerns at all"

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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 We found that this service was performing well in the areas covered by this statement. We concluded this after we * Spoke with residents * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records

Personal plans had good information about residents support needs and preferences. There were detailed routines for how residents liked to get up and go to bed. This gave staff the relevant information to work in a consistent way. The plans also had very good life histories. These life stories told staff about the person, where they were born, their families and jobs. This gave staff topics of conversation to encourage reminiscence and chat. There was evidence of regular management auditing of the plans.

The home carried out six monthly reviews of the service. This gave opportunities for the resident and their family to discuss the service with the staff and any professionals involved in their care. The personal plan was updated to show any changes. This meant that it continued to meet the needs of the resident.

Regular resident meetings were held. We looked at meeting minutes and could see that residents were consulted about the refurbishment of the home. They were shown samples of colour charts and asked to choose the ones they preferred. Residents were also asked to comment on: * Activities, were they happy with these

Springburn House, page 11 of 32 Inspection report continued * The menu * The quality of the assistance they received with personal care * The decoration of the home, were they happy with it. We could see from minutes that any issues raised were discussed again at the next meeting to report on progress. An example was the menu. Some residents had asked for more choice of fruit juices and we could see this had been done.

A small group of residents met with two members of staff to discuss social events. This meant that activities and outings were organised taking account of resident's views.

Some of the residents had advocates to speak on their behalf if they had no family to speak for them. This meant that any issues could be dealt with by an external professional rather than a staff member.

Springburn House is due to close next year as part of Glasgow City Councils plans for care of the elderly. The residents will be moving to purpose built care homes and carers had the opportunity to attend meetings with the Service Manager to give them an update on the progress of these. Residents and relatives had opportunities to visit a "mock up" of the new bedrooms and more dates were planned for this.

The home had four units. The entrance to each unit had photographs of the staff on duty that day. This informed residents and visiting relatives which staff would be there.

Each day staff and residents discussed the stories in the daily newspaper. They looked at the TV listings to choose which programmes they wanted to watch.

The home had a participation policy which included opportunities for residents to be involved in the recruitment of new staff. Residents had opportunities to meet candidates and offer opinions prior to the formal interview undertaken by service management and provider representatives. Areas for improvement There should be a clear trail of evidence to show how any complaints are investigated. We spoke with the manager about this during inspection. She told us how complaints were dealt with and the procedure for this. However there was no evidence of timescales, correspondence or actions taken on the complaints we looked at. There was little evidence of the service dealing with more low level complaints nor of actions taken to avoid formal complaints having to be made. (see Recommendation 1, under Quality Theme 1, statement 1)

We noted that although the home had consulted with residents about outing options and displayed a large list of programmed outings we were advised that due to license

Springburn House, page 12 of 32 Inspection report continued registration issues with the mini bus driver the bus could not be used for 6 weeks over the summer period. The service advised us that this had restricted outings but they were able on occasions to use taxis or other bus hire. This is a provider quality assurance issue as it appears the driver's license was not renewed on time and therefore lapsed. This then had an impact on resident outings.

The Glasgow City Council Participation Policy for Residential and Day Care Service Users and Carers would benefit from being written in plain English with a summary version available. The policy would also benefit esidentsr if it was available in other formats. This would give them greater access to this.

Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1

Recommendations 1. There should be a clear trail of evidence to show how complaints are investigated. National Care Standards, care homes for older people, Standard 5, Management and staffing arrangements

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Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths We found that this service was performing well in the areas covered by this statement. We concluded this after we * Spoke with residents * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records

In addition:

Personal plans had very detailed health information. There was a comprehensive assessment of health needs on admission to the home and this continued to be updated on a regular basis. The home used a number of tools to help residents stay healthy and safe including weekly weights, use of the MUST tool and falls diaries.

The personal plan gave details of current medication, why the resident was taking it and any possible side effects staff should look out for. This information raised staff awareness of medication and gave them additional knowledge about resident's needs. A new medication storage facility has been created to store medicines and maintain medication records. We attended two shift changeover meetings. The senior chaired this with other staff adding any relevant information. Each resident was discussed in detail and we were impressed by the level of knowledge staff demonstrated about each resident in particular with health needs. The meetings identified staff who would escort residents to any medical appointments.

Each resident had a "travelling care plan". This could be used for admission to hospital. It gave details of known allergies, medication and support needs. It also detailed things that may worry or upset the resident. During the second day of our visit one resident had to be admitted to hospital and we observed a copy of the "travelling care plan" was sent with them. This would assist hospital staff to support the resident while in hospital. A staff member accompanied the resident in the ambulance to hospital to provide reassurance.

The chef regularly consults with residents about food quality, choices and portion size and will adjust menus to take account of expressed views. Any special dietary requirements were catered for by kitchen staff. Care staff who served meals in the dining areas provided the chef with regular feedback about residents enjoyment of meals. A limited hot meal option is available at breakfast. Fluid and diet intake is

Springburn House, page 14 of 32 Inspection report continued encouraged at all times with snacks readily available. A visiting relative told us "the food is perfectly adequate." We observed lunch time. There was a relaxed calm dining experience. The tables were nicely set and arranged so that residents could chat with each other. The menu was nutritionally balanced and offered choices. Food was well presented. We saw that residents' needs were catered for by staff with support and encouragement given when required. We observed a resident being offered an alternative when he did not like the pudding. We asked residents what they thought of the food. They told us "food is good" and "they like it" Areas for improvement A provider representative, The Assistant Service Manager, was carrying out an audit of residents risk assessments on the day of inspection. We spoke with her. She told us she felt the staff had a good understanding of risks and most risk assessments were in place with review dates. However there were a few areas that needed a risk assessment carried out or needed updated. The manager was given an action plan which detailed these gaps with a timescale of 48 hours to complete. While the personal plans examined included appropriate risk assessments, we noted that there were no records of risk assessment being carried out for residents when they were going on outings. We drew this matter to the attention of the Assistant Service Manager, who was carrying out the audit, to have addressed.

The service completed daily fluid and dietary intake charts. However these were not always being filled in by staff. It is important that all staff fill these in to give a full picture of a resident's food and drink intake especially if there are concerns over weight loss or risk of dehydration.

We also noted that a number of residents regularly chose to take some or all of their meals in the bedroom rather than join other residents in the dining areas. Staff may wish to explore ways to encourage residents to have meals in the dining room with other residents. This would provide opportunities to socialise and staff would have a better chance of encouraging residents to eat and drink. A recommendation at the previous inspection identified that the MUST tool was not used consistently to monitor residents nutritional risks. As a result of the daily fluid and dietary intake charts not always being filled in this ecor mmendation is repeated. (see Recommendation 1, under Quality Theme 1, statement 3)

Two thirds of the way through reading one residents file we found that the resident was allergic to penicillin and felt this should have been clearly marked at the start of the plan.

While staff handovers were well organised and included detailed discussion about residents, it become apparent to us during our visit that sometimes common approaches were not being adopted by staff to some residents. For example, different

Springburn House, page 15 of 32 Inspection report continued members of staff provided different viewpoints about one resident who at times presented as challenging. It is imperative that there is a shared understanding of how to support people who at times may exhibit behaviour which may be challenging and have knowledge of the supports, diversions and calming techniques to assist. We found poor use of ABC charts for people whose behaviour could at times be challenging. Where charts did exist they were generally either incomplete, some had gone missing or lacked appropriate detail. The manager advised that some staff had received training in the use of ABC charts but we would recommend retraining for all staff responsible for maintaining care plans. (See Recommendation 2, under Quality Theme 1, Statement 3)

The home should provide more activities and mental and social stimulation for residents. We observed that some residents in the lounges were dozing in their chairs and a lot of residents seemed to spend most of the day in their bedrooms. We wondered if this was due to the lack of stimulating and meaningful activities. We discussed this with the manager at inspection. While we acknowledge there is now an additional "floating" staff member on each of the early and late shifts due to the lay out of the building and the needs of the residents staff had very limited time to carry out any meaningful activities. A resident told us "there's not enough to do" We spoke with a visiting professional who told us "there is a lack of activities. There are not enough staff on shift to carry out activities or 1-1 time" There is no activity coordinator to assist staff to deliver a quality activity programme. One recent resident had previously while living in the community enjoyed extensive access to day care facilities and was used to a high level of social stimulation. The manager was nominating the floating member of staff to spend an hour each day in one to one contact with this resident to address their need for social stimulation. We were advised that there was an activity folder in each of the units but when we examined them there were large gaps when either there had been no activity or it had not been recorded. It was clear from our observations that there is currently insufficient staff capable of delivering a comprehensive activity programme in addition to their other care duties. A full programme of meaningful activities would contribute to residents health and wellbeing. (see Recommendation 3 under Quality Theme 1, statement 3)

Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 3

Recommendations 1. The MUST tool should be used consistently to monitor residents nutritional needs. National Care Standards, care homes for older people, Standard 5, Management and staffing arrangements

Springburn House, page 16 of 32 Inspection report continued 2. Staff should be retrained in the completion of ABC charts National Care Standards, care homes for older people, Standard 5, Management and staffing arrangements 3. There should be a full programme of stimulating, meaningful activities National Care Standards, care homes for older people, Standard 5, Management and staffing arrangements

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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 We found that this service was performing well in the areas covered by this statement. We concluded this after we * Spoke with residents * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records

The strengths for the service user and carer involvement, detailed under Quality Theme 1, statement 1 are the same for this statement.

In addition:

The previous inspection had made a recommendation to continue to refurbish the servery areas. We could see that this had been met with work completed to a good standard. Following the last inspection two of the bedrooms had been converted for alternative use. One upstairs was now a duty room for staff to hold handover meetings and maintain records. Another had been converted into an activity room but we noted this was only used at certain times of the day. Areas for improvement The service continues to recognise the importance of close liaison with residents and relatives when planning for the move to new premises as the change of environment is likely to prove upsetting and disorienting for some residents.

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 We found that this service was performing well in the areas covered by this statement. We concluded this after we * Spoke with residents * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records

In addition:

This was an unannounced visit and we found a high standard of cleanliness.

There are regular audits of the home such as: * health and safety checks. * The provider of catering and cleaning contracts undertake regular audit of quality. * Environmental Health carry out regular food safety audits and a recent audit confirmed high standards being achieved. These contribute to keeping residents safe.

Accidents and incidents were recorded in detail. The service completed a form for each accident and incident and this was sent to the Glasgow City Council Health and Safety Group and the external manager for monitoring. This meant that if residents were having lots of accidents it would be investigated.

We sampled lunch in two of the units and found the food to be of good quality and temperature. Areas for improvement All toilets should have a bin with a cover. We found that most of the toilets had no covered bin facility. This posed an infection control issue as the bin used for any waste paper did not have a lid. We also observed that only one toilet had a working toilet role holder. Some of the holders were loose and could not be used while some toilets had none at all. (see Recommendation 1, under Quality Theme 2, statement 2)

We noted that in one bathroom the heating was not on and the window was open during what was a cold morning. In the resident lounge/dining areas not all of the heating was on when we arrived on the first morning of our inspection. While overall the heating levels of the building were adequate we feel it is important that residents are not bathed in areas which are not heated to a comfortable level. The manager

Springburn House, page 19 of 32 Inspection report continued should discuss heating at their next senior management meeting so that staff have clear instructions as to how different areas of the building should be heated.

It was brought to the manager's attention that a fire extinguisher required refixing to the wall in the smoke room and they immediately requested that arrangements be made for the work to be carried out.

Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1

Recommendations 1. All toilets should have a bin with a lid National Care Standards, care homes for older people, Standard 4, Your environment

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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 We found that this service was performing well in the areas covered by this statement. We concluded this after we * Spoke with residents * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records

The strengths for the service user and carer involvement, detailed under Quality Theme 1, statement 1 are the same for this statement.

In addition:

Residents and relatives we spoke with during inspection were all very positive about the staff. They told us "staff are good", "staff are friendly" and "staff are nice". A visiting friend told us he felt "welcomed and everyone was very friendly. Staff had been very good". Areas for improvement The service may wish to seek residents and relatives views on the management team. This would give residents further opportunities to comment on the quality of management

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 We found that this service was performing well in the areas covered by this statement. We concluded this after we * Spoke with residents * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records

In addition:

Staff had a good induction. This included Adult Support and Protection Training, moving and assisting and medication. Staff had access to further training through "Gold Training". This is an e-learning programme which includes training such as managing health and safety, violence aggression and personal safety and palliative care. Staff had or were in the process of undertaking appropriate SVQ qualifications and had or were planning to register with SSSC. Staff we spoke with told us their line managers actively encouraged and supported their professional development. The training had positive outcomes for residents as we observed staff who responded sensitively to their care needs and demonstrated high levels of knowledge about each of them.

Staff had regular supervision meetings. These sessions gave opportunities to discuss practice and training with your supervisor. Each staff member had a Personal Development Plan. This identified training and development needs with actions to be taken and target dates agreed. This ensured staff continued to develop knowledge and skills relevant to their role.

Team meetings had taken place regularly. We looked at minutes that showed discussions included care and support, the environment, training and staff changes. Staff told us they were encouraged to give their views in these meetings. Areas for improvement We noted that since the last inspection there had been a considerable number of staff changes caused by the provider readying this and other services to move to new premises. This had resulted in a number of staff being in temporary positions uncertain of if and when they would move to the new homes. A proposed change to 12 hour shifts was causing some staff anxiety as the precise times of shift patterns were unknown to staff at the time of the inspection. Senior care staff in particular

Springburn House, page 22 of 32 Inspection report continued had been affected by the staff changes and the manager was working hard to help the team gel as an effecting working group.

Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0

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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 We found that this service was performing well in the areas covered by this statement. We concluded this after we * Spoke with residents * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records

The strengths for the service user and carer involvement, detailed under Quality Theme 1, statement 1 are the same for this statement.

In addition:

The manager had an open door policy. This meant that she was readily available to meet any residents or visiting relatives about any issues they had.

The manager held regular surgeries for relatives with dates posted on the notice board. To date few people had taken up this opportunity to meet with her. The manager carried out walkabouts of all the units. This was carried out randomly so that she was in the units at different times. This gave her opportunities to observe staff practice and how they interacted with residents. It also gave opportunities for residents and staff to have a chat with her about any issues. Areas for improvement The manager should be more visible around the home. We spoke with residents and some visiting friends and relatives who told us they were not familiar with the home's manager. We discussed this with the manager at inspection. In addition to operating an open door policy the manager should raise her profile by establishing a egularr routine of spending time on the floor of the home to hear first-hand the views of people using the service. The manager might consider joining residents for lunch to help people better get to know her role while also offering her the opportunity to evaluate the residents' meal time experience.

Springburn House, page 24 of 32 Inspection report continued The manager should establish a system of recording contact with residents and visiting relatives. This would show when she had met with residents and relatives in the home but should also detail any phone calls she made to them. This would provide evidence that people had opportunities to speak with the manager about any concerns they had. (see Recommendation 1, under Quality Theme 4, statement 1)

Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1

Recommendations 1. The manager should be more visible around the home National Care Standards, care homes for older people, Standard 5, Management and staffing arrangements and Standard 11, Expressing your views

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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 We found that this service was performing well in the areas covered by this statement. We concluded this after we * Spoke with residents * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records

In addition:

The service had an Operational Plan. This showed how the service would prepare for the move to new premises. This included looking at the medication system and arranging GPs. It also included having a review of training across all units to ensure all staff had appropriate training.

There was also a Development Plan. This included the development of a new personal support plan which would focus on outcomes for residents. A Safeguarding Action Plan included falls prevention with staff being trained in this. It also included an audit of complaints with the senior team to be familiar with the procedure for dealing with these effectively and taking appropriate actions.

Changeover meetings checked the amount of petty cash and residents monies held. This was signed by staff that there was the correct amount.

The home carried out various quality checks such as: * Regular audit of personal plans * Food hygiene * Environmental audits * Medication There were action plans for any issues. This ensured the home continued to improve.

The manager had been working hard to encourage effective team working following a significant number of changes in staffing since the last inspection. Areas for improvement We noted a number of residents were up and dressed when we arrived early in the morning. Some residents had been provided with tea or coffee and we were advised that biscuits or toast could be provided. We felt 9:30 was somewhat late for residents' breakfast but were advised that pressure on staff to address the care needs of all residents in the morning would have made it difficult to serve breakfast earlier.

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A significant proportion of residents had high levels of dementia or complex medical needs with many residents requiring the assistance of two for personal care and transfers. At the previous inspection we had expressed concern about staffing levels being able to support residents care needs. Since the last inspection an additional floating member of staff had been engaged to work between units depending on each units workload. We feel staffing levels need to be further reviewed as the current pressures on care staff make being able to provide a stimulating activity programme problematic. (see Recommendation 1, under Quality Theme 4, statement 4)

We noted the manager had issued a questionnaire to staff seeking feedback about the quality of supervision, management and general support for staff. Although issued some months previously few questionnaires had been returned and where issues had been identified orf improvement these appeared not to have been addressed. The manager should develop an action plan for issues raised. This would help staff feel their views were valued. (see Recommendation 2, under Quality Theme 4, statement 4)

The provider must meet their responsibility to submit relevant notifications to the Care Inspectorate. We looked at the accident/incident log and identified incidents this year concerning residents needing medical attention and being admitted to hospital that should have had notifications submitted. While the service had dealt with these incidents correctly the Care Inspectorate should have been told about them. We spoke with the manager about this. She told us she did not realise these incidents had to be reported and she would do so in future. (see Requirement 1, under Quality Theme 4, statement 4)

The manager should hold talks with the GCC department responsible for providing drivers for the mini bus to ensure that there is no repeat of licenses being allowed to lapse. This had impacted on the residents summer outing programme.

Grade awarded for this statement: 4 - Good Number of requirements: 1 Number of recommendations: 2

Requirements 1. The provider must meet their responsibility to submit relevant notifications to the Care Inspectorate This complies with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011

Springburn House, page 27 of 32 Inspection report continued Recommendations 1. The provider should review staffing levels National Care Standards, care homes for older people, Standard 5, Management and staffing arrangements 2. The manager should develop an action plan for issues raised in staff questionnaires National Care Standards, care homes for older people, Standard 5, Management and staffing arrangements

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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 None.

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 the Care Inspectorate re-grading a Quality Statement within the Quality of Management and Leadership Theme (or for childminders, Quality of Staffing Theme) as unsatisfactory (1). This will result in the Quality Theme 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

22 Jan 2013 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership Not Assessed

27 Nov 2012 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good

29 Mar 2012 Unannounced Care and support 4 - Good Environment Not Assessed Staffing Not Assessed Management and Leadership 4 - Good

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29 Aug 2011 Unannounced Care and support 3 - Adequate Environment Not Assessed Staffing Not Assessed Management and Leadership 2 - Weak

5 Jan 2011 Unannounced Care and support 4 - Good Environment Not Assessed Staffing Not Assessed Management and Leadership 4 - Good

31 Aug 2010 Announced Care and support 4 - Good Environment Not Assessed Staffing Not Assessed Management and Leadership 4 - Good

1 Mar 2010 Announced Care and support 4 - Good Environment 4 - Good Staffing 5 - Very Good Management and Leadership 5 - Very Good

9 Mar 2010 Unannounced Care and support 4 - Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed

24 Feb 2009 Unannounced Care and support 5 - Very Good Environment 4 - Good Staffing Not Assessed Management and Leadership Not Assessed

11 Sep 2008 Announced Care and support 4 - Good Environment 4 - Good 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.

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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.

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Telephone: 0845 600 9527 Email: [email protected] Web: www.careinspectorate.com

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