lochbank manor care home service adults

Lochbank ManorCare Home Service Adults75a Graham CrescentForfarDD8 1DW

Type of inspection: Unannounced

Inspection completed on: 20 March 2015

ContentsPage No

Summary 31 About the service we inspected 42 How we inspected this service 63 The inspection 144 Other information 295 Summary of grades 306 Inspection and grading history 30

Service provided by:RDS Healthcare Limited

Service provider number:SP2005007319

Care service number:CS2008168989

If you wish to contact the Care Inspectorate about this inspection report, please callus on 0345 600 9527 or email us at [email protected]

Inspection report continued

Lochbank Manor, page 2 of 33

SummaryThis report and grades represent our assessment of the quality of the areas ofperformance which were examined during this inspection.

Grades for this care service may change after this inspection following otherregulatory activity. For example, if we have to take enforcement action to make theservice improve, or if we investigate and agree with a complaint someone makesabout the service.

We gave the service these grades

Quality of Care and Support 3 Adequate

Quality of Environment 3 Adequate

Quality of Staffing 3 Adequate

Quality of Management and Leadership 3 Adequate

What the service does wellThe service had been successful in recruitment to fill vacant posts. At the time of theinspection a full complement of staff provided stability in the delivery of care andsupport to those living in the service.

What the service could do betterThe provider must give consideration to the absence of sluice facilities in the carehome and develop interim and long-term strategies for the sanitation of equipment.

What the service has done since the last inspectionThe service has worked hard to develop care plan information and systems for theiron-going evaluation and development. This work was on-going at the time of theinspection and is intended to continue as a key area for improvement by the service.

ConclusionThe management team was committed to the ongoing development of the serviceand worked hard with the staff team to promote improvement.



1 About the service we inspectedThe Care Inspectorate regulates care services in Scotland. Information about all careservices is available on our website at www.careinspectorate.com.

This service was previously registered with the Care Commission and transferred itsregistration to the Care Inspectorate on 1 April 2011.

Requirements and recommendationsIf we are concerned about some aspect of a service, or think it could do more toimprove, we may make a recommendation or requirement.

- A recommendation is a statement that sets out actions the care service providershould take to improve or develop the quality of the service but where failure to do sowill not directly result in enforcement. Recommendations are based on the NationalCare Standards, relevant codes of practice and recognised good practice.

- A requirement is a statement, which sets out what is required of a care service tocomply with the Public Services Reform (Scotland) Act 2010 and Regulations or Ordersmade under the Act or a condition of registration. Where there are breaches of theRegulations, Orders or conditions, a requirement must be made. Requirements arelegally enforceable at the discretion of the Care Inspectorate.

Lochbank Manor is a care home service for a maximum of 40 older people. Itprovides 24-hour residential and nursing care. The two-storey home is in aresidential area about half a mile from the centre of the market town of Forfar inAngus. All rooms have an en-suite toilet and all but five an en-suite shower.Residents can also use four communal lounges, two on the ground and two on thefirst floor of the home. The home has two passenger lifts. There is a garden and carpark at the front of the house. The provider of the service is RDS Healthcare, whichhas a small number of similar services in the north of Scotland.

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

Quality of Care and Support - Grade 3 - AdequateQuality of Environment - Grade 3 - AdequateQuality of Staffing - Grade 3 - AdequateQuality of Management and Leadership - Grade 3 - Adequate

This report and grades represent our assessment of the quality of the areas ofperformance which were examined during this inspection.



Grades for this care service may change following other regulatory activity. You canfind the most up-to-date grades for this service by visiting our websitewww.careinspectorate.com or by calling us on 0345 600 9527 or visiting one of ouroffices.



2 How we inspected this service

The level of inspection we carried outIn this service we carried out a high intensity inspection. We carry out theseinspections where we have assessed the service may need a more intense inspection.

What we did during the inspectionWe wrote this report after an unannounced inspection which took place on 16 March2015, the inspection took place during day time hours. Feedback was given to themanager on 20 March 2015. The inspection was carried out by one inspector.

During the inspection we looked at Quality Theme 1, Care and Support; Quality Theme2, Environment; Quality Theme 3, Staffing; and Quality Theme 4, Management andLeadership.

Information for the inspection was gathered from a range of sources, including:- sample of personal plans- examination of written documentation, including audits and action plans- examination of staff training and personal development records- observation of the environment- discussions with a number of staff members- discussions with service users- observations of staff practice.

Grading the service against quality themes and statementsWe 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'. Undereach quality theme are 'quality statements' which describe what a service should bedoing well for that theme. We grade how the service performs against the qualitythemes 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 ourinspections. These are extra checks we make on top of all the normal ones we makeduring inspection. We do this to gather information about the quality of these aspectsof care on a national basis. Where we have examined an inspection focus area we willclearly identify it under the relevant quality statement.



Fire safety issuesWe do not regulate fire safety. Local fire and rescue services are responsible forchecking services. However, where significant fire safety issues become apparent, wewill alert the relevant fire and rescue services so they may consider what action totake. You can find out more about care services' responsibilities for fire safety atwww.firelawscotland.org



What the service has done to meet any requirements we made atour last inspection

The requirementThe provider must develop a quality assurance system to ensure that all aspects ofthe service are improved. In order to achieve this the provider must:

- have clear guidance for staff on timescales for audits and the content of these- clearly record what required action has been identified as a result of an audit- ensure that staff undertaking audits within the service receive appropriate trainingdetailing the expectation of the audit, how to monitor outcomes and record follow-upto the actions implemented to make improvements.

This is in order to comply with:The Social Care and Social Work Improvement Scotland (Requirements for CareServices) Regulation 2011, Scottish Statutory Instrument 2011/210Regulation 4 -Welfare of Users.This requirement also takes account of The National Care Standards for Care Homesfor Older People - Standard 5: Management and Staffing Arrangements.Timescale: to commence on receipt of this report and be completed by 31 May 2014.

What the service did to meet the requirementThis has been reported under quality theme 4, statement 4. Please refer to thissection of the report for information.

The requirement is: Met - Within Timescales

The requirementThe provider must ensure that the complaints procedure identifies a timescale of 20working days for dealing with complaints.

This is to comply with:

The Social Care and Social Work Improvement Scotland (Requirements for CareServices) Regulations 2011, Scottish Statutory Instrument 2011/210 Regulation 18(4) -a requirement to inform he complainant within 20 working days of any action that isto be taken following their complaint to the service.



Timescale for Implementation: within one week from receipt of this report.

What the service did to meet the requirementThe timescale for investigating complaints had been updated to reflect thisrequirement. However; we have made a recommendation relating to complaints inquality theme 4, statement 4.

The requirement is: Met - Within Timescales

What the service has done to meet any recommendations we madeat our last inspectionFifteen recommendations for improvement were made at the last inspection:

Recommendation:Care plans should be progressed to include information about service users individuallikes and preferences.

Action taken:This was being progressed on an ongoing basis.

Recommendation:Information should be made available to service users at meal times.

Action taken:we saw a blackboard with the meal options displayed in the dining area. Thisinformed individuals of what was available to them for their meals.

Recommendation:Systems should be in place to review legal orders such as section 47 certificates(Adults with Incapacity (Scotland) Act 2000.

Action taken:This had been undertaken; the plans sampled by us were seen to have a currentcertificate of incapacity. A system had been introduced to check the expiry dates ofsuch certificates and plan for them to be reviewed with the relevant medicalpractitioner.



Recommendation:Support plans should be updated timeously to accurately reflect individual need.

Action taken:This work was on-going; we have made a further recommendation in relation to careplans. See quality theme 1, statement 3.

Recommendation:Laundry bags should be stored in a manner that promotes effective infection control.

Action taken:Laundry bags remained in the corridor; however they were regularly emptied.Consideration should be given to their storage; this may be done along with theconsideration of the sluice facility.

Recommendation:Activity planning should promote physical activity.

Action taken:We have made a recommendation about enhancing activities under quality theme 1,statement 3.

Recommendation:Consideration should be given to regular checks of the nurse call system and amaintenance contract to help ensure they remain in good working order.

Action taken:repairs were made to the nurse call system following the last inspection. At the timeof the inspection it was in good working order. Approval had been given by theprovider for the nurse call system to be upgraded. We will follow-up the progress ofthis at our next inspection.

Recommendation:Consideration should be given to external maintenance to help maintain the exteriorof the building.

Action taken:Some external maintenance work had been undertaken since the last inspection.



Recommendation:Plans should be put in place to repair the internal damage caused by rainwater.

Action taken:repairs to the water damaged décor had taken place.

Recommendation:A dementia friendly environmental audit would help the service identify and plan howthe environment can be enhanced to aid orientation for service users with a diagnosisof dementia.

Action taken:This recommendation remains outstanding.

Recommendation:Safe recruitment practice should be fully implemented during staff recruitment.

Action taken:We sampled staff files and were confident that safer recruitment practice was beingimplemented.

Recommendation:Arrangements for staff meetings should take account of the needs of both day andnight workers.

Action taken:Staff meetings had taken place to accommodate the needs of both day and nightstaff.

Recommendation:A quality assurance framework should be developed to identify what aspects of theservices performance is to be measured and the timescales for completion noted.

Action taken:We have reported on this under quality theme 4, statement 4. Please refer to thissection of the report for information.



Recommendation:The service should undertake a dependency assessment of service users needs anduse this information to inform the planning for staffing the home.

Action taken:We have reported on this under quality theme 4, statement 4. Please refer to thissection of the report for information.

Recommendation:A development plan for the service would help identify the key priorities forimprovement for the service and give a shared vision to all relevant stakeholders.

Action taken:This remains outstanding. We have repeated the recommendation in quality theme 4,statement 4. Please refer to this section of the report for information.

The annual returnEvery year all care services must complete an 'annual return' form to make sure theinformation we hold is up to date. We also use annual returns to decide how we willinspect the service.Annual Return Received: Yes - Electronic

Comments on Self AssessmentEvery year all care services must complete a 'self assessment' form telling us howtheir service is performing. We check to make sure this assessment is accurate.An updated self assessment was not required for this inspection.

Taking the views of people using the care service into accountWe spoke with six service users individually during the inspection. It was not alwayspossible to ascertain their level of satisfaction with the service provided; however fourof the six did express a high level of satisfaction. Individual comments included:

"It's lovely in here, I'm very happy. I have no complaints; the food is very good."

"The girls are all lovely, I'm very comfortable."

"I like to go out and get these feet moving."



Taking carers' views into accountThere were no relatives or visitors present during the inspection.



3 The inspectionWe looked at how the service performs against the following quality themes andstatements. Here are the details of what we found.

Quality Theme 1: Quality of Care and SupportGrade awarded for this theme: 3 - Adequate

Statement 1We ensure that service users and carers participate in assessing and improving thequality of the care and support provided by the service.

Service strengthsExamination of the evidence presented in respect of this quality statement assessedthe service to be operating at an adequate level of performance.

The service had continued to build on ways of involving service users and theirrepresentatives in the development of the service and we found some evidence ofchanges being introduced based on comments made by them at a formal meeting.Some service users had said that they had to wait too long to get their breakfast inthe morning; staff started earlier in the morning to address this. Comments had alsobeen made that some individuals wished a CD to be played at mealtimes rather thanthe radio; we saw this in operation.

A keyworker system was in place and an update of staff allocated to service userswas in progress. Staff were familiar with their responsibilities of this role whichincluded a link between the service and home to ensure service users had all theyneeded for daily life. A communication book was in place to help promotecommunication.

A noticeboard was at the entrance to the home which detailed information aboutlocal and important events. In addition a newsletter was issued on a planned andregular basis. This helped keep people informed about events and importantinformation.

Service users and/or their representatives were invited to formally discuss how wellthe service was meeting their needs. This meant that changes and updates couldtake place if required.



Some of the care file documentation had been enhanced to provide information in a"pen picture" of each service user. This helped staff get to know them better andunderstand their individual needs and preferences.

Areas for improvementAlthough activities were planned to help create meaningful opportunities there wasno evidence to support consultation with service users to have their wishesincorporated in to the programme. See quality theme 1, statement 1, recommendation1.

The service should continue to build on ways in which it could involve those living atthe care home and their representatives in the evaluation and development of theservice.

Grade awarded for this statement: 3 - Adequate

Number of requirements: 0

Number of recommendations: 1

Recommendations

1. Consideration should be given to the evaluation of the programme of activities toinclude opportunities and suggestions made by those living in the care home.National Care Standards for Care Homes for Older People: Standard 11 -Expressing your view.National Care Standards for Care Homes for Older People: Standard 17 -Daily life.



Statement 3We ensure that service users' health and wellbeing needs are met.


Service users appeared well-groomed, some ladies wore jewellery and had their nailspainted and those who required glasses to aid their vision had been supported towear them.

Each service user had a care plan outlining how staff were to support them to havetheir needs met. These were informed by a range of health assessments todetermine risk factors that required preventative interventions or strategies to supporttheir wellbeing. Staff were responsive to the changing needs of those living at theservice. We examined a sample of plans and found good evidence of involvement ofexternal health professionals to provide treatment, guidance and support to meethealth needs.

We did not examine systems for medication management but were confident that themanagement team were monitoring and developing this through ongoing audit,assessment and training.

We observed a meal time experience. Service users were offered choice; the mealoptions displayed on a blackboard in the dining room. During our observations wesaw staff supporting individuals to have their meals offering encouragement andsupport as required.

The management team were familiar with the requirements of the Adults withIncapacity Act (Scotland) 2000 and had considered the implications for those living atthe care home who lacked capacity to make their own decisions. Documentationrelating to consent to treatment had been reviewed and updated by relevant medicalstaff where required.



Areas for improvementWe examined wound documentation. There was obvious confusion among staff overthe completion of the documentation in use. There was duplication of somedocumentation in different tools that were required to be completed and it wasdifficult to ascertain that wounds had been managed in a way that was compliantwith the planned regime. Wound photography was used but it was often out of focusand lacked detail to identify the name of the service user, the wound site and thedate the photograph had been taken. See quality theme 1, statement 3, requirement1.

A new system had recently been introduced to prompt the evaluation of care plansand assessment tools, despite this we found some evaluations and updates had nottaken place as planned. See quality theme 1, statement 3, recommendation 1.

We looked in fridges in pantry areas and found supplies of semi-skimmed milk. Therewere no alternatives to this available for use. Full fat milk should be the main choicefor older people with assessments for alternatives being in plans. See quality theme 1,statement 3, recommendation 2.

Grade awarded for this statement: 3 - AdequateNumber of requirements: 1Number of recommendations: 2

Requirements1. The provider must review and update wound documentation to ensure effective

assessment, planning and evaluation in wound management.This is in order to comply with:The Social Care and Social Work Improvement Scotland (Requirements forCare Services) Regulations, Scottish Statutory Instruments 2011 No 210:regulation 4(1)(a) - requirement for the health and welfare of service users.Timescale for completion: Within 4 weeks of receipt of this report.

Recommendations1. Consideration should be given to reviewing the implementation of the system for

care plan evaluation to ensure it is being effectively implemented.National Care Standards for Care Homes for Older People: Standard 5 -Management and staffing.



2. Nutritional guidance for older people should be fully implemented; in particular theuse of full fat milk as the main option.National Care Standards for Care Homes for Older People: Standard 13 -Eating well.Care Inspectorate Guidance - Care Homes for Older People Best PracticeStandards and Guidance on Food, Fluid and Nutrition Publication code:HCR-1214-089 was taken in to account in making this recommendation.



Quality Theme 2: Quality of EnvironmentGrade awarded for this theme: 3 - Adequate

Statement 1We ensure that service users and carers participate in assessing and improving thequality of the environment within the service.

Service strengthsThe information contained in quality theme 1, statement 1, is also relevant to thisstatement. Please refer to this section of the report for information on participation.

Areas for improvementThe information contained in quality theme 1, statement 1, is also relevant to thisstatement. Please refer to this section of the report for information on participation.




Statement 2We make sure that the environment is safe and service users are protected.


A secure entry system was in operation and visitors to the home were requested tosign in and out when entering or leaving the building. This helped maintain anaccurate record who was in the building at any one time.

Since the last inspection there had been some repairs carried out to water damage inthe upstairs lounge. This meant that the living environment had been enhanced forthose accessing the lounge.

Maintenance staff employed in the service carried out routine safety checks andrepairs to help promote safety. Large pieces of equipment were maintained byexternal providers where required; contracts were in place to support this.

The development of the garden continued; there was some involvement of serviceusers and their representatives in the planning of the project.

At the last inspection the nurse call system was not working properly and there wasno maintenance contract to support its prompt repair. The provider had sinceobtained a quote for an upgraded system; this had been approved and the managerconfirmed that it was to be installed. We will monitor the progress of this throughour ongoing regulatory activity.

Personal protective equipment including disposable gloves and aprons was availableto staff to support the implementation of infection control procedures. We sawsupplies in toilet areas, bathrooms and individual bedrooms.

A range of manual handling equipment was available to support safe practice whenassisting those with mobility difficulties to change position.

Areas for improvementThe service had no sluice facility to support the sanitation of bed pans; the currentcleaning arrangements in facilities used for personal care was considered tocompromise the control of infection. See quality theme 2, statement 2, requirement 1.



Some of the carpet areas had hazard tape covering areas of damage that indicated atrip hazard. This tape was evident at the last inspection and there were no approvedplans for repair or replacement. Although the trip risk to service users had beenminimised as the damage had been covered with the hazard tape it was notappealing to the eye and did not promote a positive living environment. See qualitytheme 2, statement 2, recommendation 1.

Oxygen therapy was in use in the care home. A hazard warning was in place, thiswas written text on white paper; the interpretation of this was dependent on theability of people's to read the written text. This was considered to be inadequate. Seequality theme 2, statement 2, recommendation 2.

The laundry facilities were considered to be inadequate. There was no separate entryor exit for clean and dirty linen to promote best practice and there was only onemachine for washing; this did not allow for breakdown of equipment or error. Seequality theme 2, statement 2, recommendation 2.


Requirements1. The provider must promote effective systems for the control of infection. In order to

achieve this the provider must:- provide interim guidance for staff on the disposal of bodily waste and thesanitisation of associated equipment- develop a plan for the long term management of the disposal of bodily waste andthe sanitisation of associated equipment.- provide a copy of the development plan to the Care Inspectorate with timescalesof how the service intends toimplement the long term strategy.This is in order to comply with Social Care and Social Work ImprovementScotland (Requirements for Care Services) Regulations SSI 210/2011,Regulation: 4(1)(d) Infection control.Care Inspectorate Publication: Building Better Care Homes for Adults -Publication Code OPS-1213-257 was taken in to account in making thisrequirement.Timescale for implementation: Within 3 weeks of receipt of this report.

Recommendations1. Consideration should be given to the repair of floor coverings that have hazard

warning tape.



National Care Standards for Care Homes for Older People: Standard 4 - Yourenvironment.

2. Consideration could be given to the upgrading of laundry facilities to promote moreeffective infection control procedures.National Care Standards for Care Homes for Older People: Standard 4 - Yourenvironment.



Quality Theme 3: Quality of StaffingGrade awarded for this theme: 3 - Adequate

Statement 1We ensure that service users and carers participate in assessing and improving thequality of staffing in the service.

Service StrengthsThe information contained in quality theme 1, statement 1, is also relevant to thisstatement. Please refer to this section of the report for information on participation.

Areas for improvementThe information contained in quality theme 1, statement 1, is also relevant to thisstatement. Please refer to this section of the report for information on participation.




Statement 3We have a professional, trained and motivated workforce which operates to NationalCare Standards, legislation and best practice.


We spoke with a number of staff who were generally positive about working as partof the team at Lochbank Manor. They told us that they felt things were moving in theright direction and they were confident and supportive with the leadership of thesenior team.

Systems were in place to support the personal and professional development of staff.Staff had access to a range of training events and a schedule of planned events wasin place. Staff development groups had been recently introduced bringing staff fromall disciplines together to discuss topics and evaluate practice. This was considered tobe a positive development. Formal supervision and appraisal was being progressedproviding an opportunity for each staff member to discuss and evaluate theiremployment, knowledge and skill along with their supervisor. This helped promote aprofessional and trained workforce.

All care staff were registered or were in the process of registering with theirprofessional body. Management regularly checked to ensure that staff remained onthe register. This meant that staff were accountable to their relevant Codes ofPractice.

We sampled recruitment files of recently employed staff. This confirmed that theservice was compliant with the implementation of best practice guidance. Tworeferences were sought as part of the assessment process, one of which was fromtheir most recent employer.

Areas for improvementSystems were in place to promote communication amongst the team, however wefound examples of miscommunication that had the potential to be detrimental to thewellbeing of service users. For example, in relation to wound management: careplans, daily diary and verbal handover advised on the frequency of dressing change.These were not consistent. We were also advised that staff starting early morning didnot get a formal handover along with the rest of the day staff. This meant that theydid not always know about planned daily events including hospital appointments. Seequality theme 3, statement 3, recommendation 1.



As detailed in quality theme 2, statement 2, the service did not have a sluice facilityto effectively manage the sanitation of equipment including bed pans. This practiceimplemented by staff to sanitize equipment compromised the control of infection. Seequality theme 3, statement 3, recommendation 2.


Recommendations1. Communication systems should be enhanced to ensure that staff have the

necessary information to ensure the wellbeing of service users.National Care Standards for Care Homes for Older People: Standard 5 -Management and staffing.

2. Consideration should be given to reviewing staff practice of sanitising bed pansand other associated equipment to promote the implantation of effective infectioncontrol practice.National Care Standards for Care Homes for Older People: Standard 5 -Management and staffing.



Quality Theme 4: Quality of Management and LeadershipGrade awarded for this theme: 3 - Adequate

Statement 1We ensure that service users and carers participate in assessing and improving thequality of the management and leadership of the service.

Service strengthsThe information contained in quality theme 1, statement 1, is also relevant to thisquality statement. Please refer to this section of the report for information onparticipation.

Areas for improvementThe information contained in quality theme 1, statement 1, is also relevant to thisquality statement. Please refer to this section of the report for information onparticipation.




Statement 4We use quality assurance systems and processes which involve service users, carers,staff and stakeholders to assess the quality of service we provide.


A quality framework had been introduced; this identified what aspects of the servicewere to be measured, the quality indicators they were to be measured against, whowas to carry out the assessment and when it was to be done. This was beingimplemented by the management team and formed the basis for developments in theservice.

Dependency assessments were undertaken on a planned and regular basis. We foundsome evidence that these had been used to influence amendments to the staffingcompliment to meet the needs of service users. This confirmed that the service hadbeen responsive to need.

A system was in place for accident and incident reporting. These were monitored andreviewed by the management team to help ascertain actions that could be taken ortrends that could be addressed to promote safety and wellbeing.

The service had a valid certificate of insurance displayed at the entrance to the home.

An independent consultant helped monitor the services performance.

Areas for improvementThe service did not have a development plan. We have identified some key issues ofdeficit in this report that required a planned approach for improvement. In particularin relation to a sluice facility, improvements to the laundry and the damaged carpets.See quality theme 4, statement 4, recommendation 1.

A complaints policy and procedure was in place; we sampled documentation relatingto issues of concern/complaint that had been brought to the attention of themanagement team. It was difficult to track how the service had responded to theseand how agreed actions had been progressed. It would be helpful to have amonitoring tool to check against the implementation of the procedure and an actionplan to measure progress on agreed actions. See quality theme 4, statement 4,recommendation 2.



Formal meetings with service users and their representatives took place, howeverthere was not always a plan of action on how the service aimed to implement agreedsuggestions/developments. See quality theme 4, statement 4, recommendation 3.

Accident and incident documentation was reviewed by management. However therewas no information to identify what action had been taken at the time of theaccident/incident. See quality theme 4, statement 4, recommendation 4.


Recommendations1. A service development plan would identify key improvements for the service and

confirm the providers commitment to ongoing service development.National Care Standards for Care Homes for Older People: Standard 5 -Management and staffing.

2. Consideration should be given to introducing a framework for progressing andmonitoring actions taken in relation to complaints.National Care Standards for Care Homes for Older People: Standard 5 -Management and staffing.

3. The use of action plans should be considered to capture what actions the serviceintends to take on comments and suggestions made by service users and/or theirrepresentatives.National Care Standards for Care Homes for Older People: Standard 5 -Management and staffing.

4. Consideration should be given to implementing a system for recording what actionhad been taken at the time of an accident/incident to promote the safety andwellbeing of the individuals concerned.National Care Standards for Care Homes for Older People: Standard 5 -Management and staffing.



4 Other information

ComplaintsNo complaints have been upheld, or partially upheld, since the last inspection.

EnforcementsWe have taken no enforcement action against this care service since the lastinspection.

Additional InformationNone noted.

Action PlanFailure to submit an appropriate action plan within the required timescale, includingany agreed extension, where requirements and recommendations have been made,will result in the Care Inspectorate re-grading a Quality Statement within the Qualityof Management and Leadership Theme (or for childminders, Quality of StaffingTheme) as unsatisfactory (1). This will result in the Quality Theme being re-graded asunsatisfactory (1).



5 Summary of grades

Quality of Care and Support - 3 - Adequate

Statement 1 3 - Adequate


Quality of Environment - 3 - Adequate



Quality of Staffing - 3 - Adequate



Quality of Management and Leadership - 3 - Adequate



6 Inspection and grading history

Date Type Gradings

21 Jul 2014 Unannounced Care and support 3 - AdequateEnvironment 3 - AdequateStaffing 3 - AdequateManagement and Leadership 3 - Adequate

25 Feb 2014 Unannounced Care and support 2 - WeakEnvironment 3 - AdequateStaffing 3 - AdequateManagement and Leadership 2 - Weak

8 Feb 2013 Unannounced Care and support Not AssessedEnvironment 4 - GoodStaffing 4 - GoodManagement and Leadership Not Assessed



4 Jun 2012 Unannounced Care and support 4 - GoodEnvironment Not AssessedStaffing Not AssessedManagement and Leadership 4 - Good

8 Feb 2012 Unannounced Care and support 3 - AdequateEnvironment Not AssessedStaffing 3 - AdequateManagement and Leadership 3 - Adequate

22 Nov 2011 Unannounced Care and support 3 - AdequateEnvironment Not AssessedStaffing Not AssessedManagement and Leadership 3 - Adequate

17 Oct 2011 Unannounced Care and support 2 - WeakEnvironment Not AssessedStaffing Not AssessedManagement and Leadership Not Assessed

15 Aug 2011 Unannounced Care and support 2 - WeakEnvironment Not AssessedStaffing 3 - AdequateManagement and Leadership 2 - Weak

21 Jul 2011 Unannounced Care and support 2 - WeakEnvironment Not AssessedStaffing 3 - AdequateManagement and Leadership 2 - Weak

8 Jun 2011 Unannounced Care and support 2 - WeakEnvironment Not AssessedStaffing 2 - WeakManagement and Leadership 2 - Weak

10 Mar 2011 Unannounced Care and support 2 - WeakEnvironment Not AssessedStaffing 2 - WeakManagement and Leadership 2 - Weak



22 Dec 2010 Announced Care and support 2 - WeakEnvironment Not AssessedStaffing 2 - WeakManagement and Leadership 2 - Weak

21 Jul 2010 Announced Care and support 2 - WeakEnvironment 3 - AdequateStaffing 2 - WeakManagement and Leadership 2 - Weak

26 Feb 2010 Unannounced Care and support 2 - WeakEnvironment 3 - AdequateStaffing Not AssessedManagement and Leadership Not Assessed

9 Dec 2009 Unannounced Care and support 3 - AdequateEnvironment Not AssessedStaffing 2 - WeakManagement and Leadership Not Assessed

10 Jun 2009 Announced Care and support 3 - AdequateEnvironment 3 - AdequateStaffing 2 - WeakManagement and Leadership 3 - Adequate

All inspections and grades before 1 April 2011 are those reported by the formerregulator of care services, the Care Commission.



To find out more about our inspections and inspection reportsRead our leaflet 'How we inspect'. You can download it from our website or ask us tosend you a copy by telephoning us on 0345 600 9527.

This inspection report is published by the Care Inspectorate. You can get more copiesof this report and others by downloading it from our website:www.careinspectorate.com or by telephoning 0345 600 9527.

Translations and alternative formatsThis inspection report is available in other languages and formats on request.

Telephone: 0345 600 9527Email: [email protected]: www.careinspectorate.com



lochbank manor care home service adults

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