Penumbra - Queens Drive Care Home Service Adults Suite 1 Epoch Business Centre Falkirk Road Grangemouth FK3 8WW Telephone:

Transcription

1 Penumbra - Queens Drive Care Home Service Adults Suite 1 Epoch Business Centre Falkirk Road Grangemouth FK3 8WW Telephone: Inspected by: Jane Lynch Type of inspection: Unannounced Inspection completed on: 19 December 2012

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 10 4 Other information 23 5 Summary of grades 24 6 Inspection and grading history 24 Service provided by: Penumbra Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Jane Lynch Telephone enquiries@careinspectorate.com Penumbra - Queens Drive, page 2 of 26

3 Summary This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change after this inspection following other regulatory activity. For example, if we have to take enforcement action to make the service improve, or if we investigate and agree with a complaint someone makes about the service. We gave the service these grades Quality of Care and Support 5 Very Good Quality of Environment 5 Very Good Quality of Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well The service provides high quality person - centred care that is flexible and responsive to the individual needs of people they support. They have very good ways of ensuring that people can stay as safe, healthy and well as possible. They support people to achieve goals and ambitions and to have a positive quality of life. The service has excellent ways that they involve people in giving their views about the quality of the service to enable them to have the opportunity to be heard and involved in decisions that affect them. What the service could do better The service should continue to develop how they monitor the service to make sure high standards are maintained. As part of the continued professional development of staff reflective practice needs to be developed and evidence folders needed to be maintained to satisfy SSSC. What the service has done since the last inspection Since the last inspection a new management team had been recruited. We found that there had been improvements made to the quality of the service as a result and that there was a development plan in place indicating future improvement ideas. Penumbra - Queens Drive, page 3 of 26

4 We found that the house had been decorated with tenants involved in choosing the new colour schemes and in purchasing the new home furnishings. Conclusion Overall, we found that the service provides a high standard of care and support against the Quality Statements considered during our inspection. The service should continue to build on strengths and take forward areas for improvement. Who did this inspection Jane Lynch Penumbra - Queens Drive, page 4 of 26

5 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 This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April Requirements and recommendations If we are concerned about some aspect of a service, or think it needs to do more to improve, 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 based on best practice or the National Care Standards. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reform (Scotland) Act 2010 ("the Act") and secondary legislation made under the Act, or a condition of registration. Where there are breaches of Regulations, Orders or conditions, a requirement may be made. Requirements are legally enforceable at the discretion of the Care Inspectorate." Penumbra Queens Drive offers accommodation with care and support to a maximum of four adults with mental health problems. Support is provided directly between 9am and 9pm and the staff team offer an on call system of support outwith these times. The service, which is located in a quiet residential area of Falkirk, occupies a detached house with accommodation over two floors. All service users have their own bedroom with communal bath/shower room facilities. The accommodation is well furnished and has a homely feel. At the time of the inspection four people were accommodated within the service on a continuing basis. There was a statement of aims and objectives in place which confirms the organisations commitment to "offer flexible and responsive support to people experiencing social, behavioural or mental health difficulties". Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 5 - Very Good Quality of Environment - Grade 5 - Very Good Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 5 - Very Good Penumbra - Queens Drive, page 5 of 26

6 This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. Penumbra - Queens Drive, page 6 of 26

7 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 The inspection was carried out by Inspector Jane Lynch. An unannounced inspection took place on 10 December We visited the the house on 10 December 2012 to speak with tenants and staff and to examine records and other documentation. We observed the environment including being invited into tenants bedrooms to see how they had been decorated. Feedback was given to the manager, the depute manager and an external manager on 19 December During this inspection we gathered evidence from various sources. These included: Policy and procedure Involvement and participation invitation letters Photographs of people involved in engagement opportunities Three personal plans New personal plan format Service diary Communication book Staff files including training records Accident and incident records Complaint documentation Service questionnaires Recording formats used for quality assurance processes Strategic Plan for organisation West Area Development Plan Falkirk Service Plan Meeting minutes including review and team meeting minutes Discussion with the Manager Discussion with the Depute Manager Discussion with two Support Workers Discussion with three people using the service Penumbra - Queens Drive, page 7 of 26

8 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 report continued 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 Penumbra - Queens Drive, page 8 of 26

9 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 service submitted a fully completed self assessment document to us before we carried out our inspection. The service told us what they thought they did well, some areas for improvement and how they planned to take these forward. The sources of evidence given by the service provided a useful starting point for our inspection. The service could continue to develop self assessment to link specific inputs and outputs to outcomes for people. They could give some examples of the changes that have been made, over time, as a result of service users' involvement and participation. Taking the views of people using the care service into account We spoke with three tenants who told us about the support that they received. They said "staff help you if you've got a problem" Tenants spoke about their current goals and also their long term goals. For example getting their own tenancy. The tenants told us about the various social events that they had been involved in both in the house and out in the community. They said that they were able to agree or suggest activities at tenant meetings or through discussion with their key worker. Tenants told us about their involvement in National events and how they had taken part. Examples included talking about the new personal plan format to a management group and helping at a stall during the Penumbra Roadshow that promoted healthy eating. Taking carers' views into account At this inspection we were unable to talk with carers. Penumbra - Queens Drive, page 9 of 26

10 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 5 - Very 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 the service had been performing to an excellent level in this statement. We reached this conclusion after: Examining the Service user and care involvement policy and procedure Discussion with the manager and staff Discussion with people using the service. Observation of practice People were advised of the benefits and encouraged to be involved in giving their views about the service through information contained in newsletters and the distribution of information leaflets. The information raised people's awareness of their right to complain if dissatisfied with the service being delivered. A process of consultation had identified peoples preferred methods of engagement. We found a variety of engagement opportunities that people had been involved in to give their views about the service at both a local and National level. They included: Involvement in recruitment Managers open hour held on a regular basis Feedback slips distributed to people using the service Involvement in Penumbra Road show Resident meetings at both local and National level Survey questionnaires Penumbra - Queens Drive, page 10 of 26

11 Focus groups facilitated by people using the service Organisational annual gathering Training/information events for people using the service Support plan meetings and reviews We found that Penumbra welcomed the views of people using the service and their carers to inform research and development of initiatives to improve service delivery. The strategic plan informed services of future goals in how services would be delivered and identified how services were expected to develop at a local level. The service used 'You said we did' to show people how their suggestions and views had resulted in improved service delivery. We saw excellent examples of people developing new hobbies through making suggestions about new hobbies and being supported to try them out. The newsletter informed people of general improvements to the service as a result of any surveys or other engagement opportunities. Recent engagement had focused on quality of staff and the introduction of the new personal plan. We saw how the results were used to shape the service with people benefiting from a service that took into account their preferences and wishes. We saw how tenants views and wishes had been taken into account during the redecoration of the house. One tenant said that after the house being decorated they felt that they wanted to keep all areas clean and tidy. Areas for improvement The service should evaluate the effectiveness of the involvement and participation opportunities to ensure that they are meaningful to people and that the process results in good assessment of the quality of the service being delivered. The service had been developing the involvement and participation of people in the formal process of staff performance monitoring. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Penumbra - Queens Drive, page 11 of 26

12 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Inspection report continued We found that the service was performing to a very good level in this statement. We reached this conclusion through: Speaking with people using the service Examining three personal plans Discussion with the manager and staff Examining staff training records We found that tenants we talked with took ownership of their personal plan and were able to show us how the plan highlighted their individual health and wellbeing needs with detail of the care and support required. We saw how the views of other stakeholders shaped the care and support delivered to ensure that individual health and wellbeing needs were met. The focus was on supporting people as individuals with their recovery so that they would be able to manage their mental health and have a good quality of life. We saw how the service used the 'Wellness Recovery Action Plan' (WRAP) to work with people so that they were developing an awareness of how to keep well. For example the WRAP documented signs that the person recognised as being signs when they were well or early signs that their mental health was deteriorating. This helped the person to recognise when they needed help from staff or other health professionals. Where necessary a pictorial format was used to ensure people were able to communicate and understand the detail in the personal plan. We found very good examples of people using the service being supported by staff to keep safe and well. They included the promotion of a healthy lifestyle through diet, exercise and social experience and supporting people to attend health appointments. Tenants spoken with told us that being supported by staff to attend appointments gave them confidence and minimised the stress felt at having to attend the appointments. One tenant said "I want to give up smoking and so does my key worker so we're going to do it together." We found that staff accessed training and had an knowledge of best practice guidance that provided them with an awareness of how to support people using the service with their health and wellbeing needs. Staff were aware of their duty to pass concerns about people's health to their line manager. This enabled service users to receive the care and support required either through a change to the service or through a referral to the appropriate health professional. Penumbra - Queens Drive, page 12 of 26

13 Areas for improvement We found that the organisation was making a transition to a new format of personal plan called the 'HOPE toolkit'. The service planned to implement the new format for all people using the service as part of their next review. The service should include an assessment of need in the personal plan to show how a decision is reached about the level of care and support required. For example with medication. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Penumbra - Queens Drive, page 13 of 26

14 Quality Theme 2: Quality of Environment Grade awarded for this theme: 5 - Very 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 Similar to Quality Theme 1, statement 1. We found opportunities for people using the service and other stakeholders to give their views about the quality of the environment. The service currently encourages people to express their views about the quality of the environment through the various opportunities described in Quality Theme 1, statement 1. We found that people using the service had been involved in choosing how their bedrooms and communal areas in the house would be decorated and shopping for soft furnishings. Areas for improvement The service should consider the areas for improvement highlighted in Quality Theme 1, statement 1. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Penumbra - Queens Drive, page 14 of 26

15 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths Inspection report continued We found that the environment was safe and that tenants were protected to a very good level. We reached this conclusion through examining a range of policy and procedure and recording systems, observation of the premises and discussion with the manager and staff. Policy and procedure guided staff in how to safeguard people using the service. We sampled a range of records and other documentation maintained to show that the safety of the environment was regularly monitored. This ensured that risks were minimised to safeguard people living in the service. Examples included: Fire drill records Risk assessments Cleaning records Infection control recording Temperature checks Observation of the environment, including the outdoor area, confirmed that it was safe and a general environmental risk assessment showed how the service minimised any risk. We sampled staff training records and found that they had received training and development opportunities to ensure that they were knowledgeable about best practice in protecting people and in maintaining a healthy and safe environment. Training opportunities included: Health and Safety Infection control Food safety Fire training First aid Staff and resident meeting minutes confirmed that safety of the environment was regularly discussed. This ensured that people were reminded about maintaining the safety of the environment and the benefits of living in a safe and secure environment. Comments for people using the service included: "We've been looking after the house and keeping it clean and tidy since it was all decorated". Penumbra - Queens Drive, page 15 of 26

16 "I feel safe here." Areas for improvement The service identified the need to continue to review procedures to ensure a safe environment for people living there. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Penumbra - Queens Drive, page 16 of 26

17 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths Similar to Quality Theme 1, statement 1. We found opportunities for service users and carers to give their views about the quality of the staff team. The service currently encourages people to express their views about the staff that support them through the various opportunities described in Quality Theme 1, statement 1. We found an excellent example of how people using the service had been involved in assessing the quality of staff through the recruitment process. The service had formally invited people to a recent a recruitment of staff and had provided a pack to support them with taking part in the process. People said they had enjoyed the experience and that managers had listened to their views about which candidate they had preferred. Areas for improvement The service should consider the areas for improvement highlighted in Quality Theme 1, statement 1. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Penumbra - Queens Drive, page 17 of 26

18 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths Inspection report continued We found that the service was performing to a very good level in this statement. The service implemented corporate policy and procedure that led to a professional trained staff team taking account of legislation and best practice. Policy included: Recruitment Staff development Staff supervision We found that the service implemented a process of continued staff development. The process included: Regular supervision and appraisal sessions including continued training needs analysis. A training plan that included mandatory and other relevant training opportunities. A record of training staff had attended. Evaluation of training accessed by staff. Team meetings We found that people using the service benefited from being supported by a staff team that was competent in delivering a service that met individual care and support needs. Staff were supported to identify any training needs and access training that would develop their knowledge and understanding of people's individual care and support needs. Best practice guidance we found readily available included 'The New Mental Health Act'; 'ASP Forth Valley Guidance' Mental Welfare Commission articles and NHS 'Scotland Delivering for Mental Health'. Staff were also signposted to useful weblinks. There were opportunities for staff to attain a Scottish Vocational Qualification (SVQ) enabling them to develop their knowledge and understanding of good practice and attaining a suitable qualification to satisfy Scottish Social Services Council (SSSC) in preparation for registration. At the inspection only four staff still had to complete SVQ qualification. Penumbra - Queens Drive, page 18 of 26

19 Staff that we talked with said that they felt involved in the development of the service at a local level and Nationally. We found that staff had opportunities to become 'champions' in aspects of the service delivery. For example staff had become self directed support champions. This meant that they had been involved in National training and were responsible for disseminating the information to colleagues locally. Staff said that they found team meetings and supervision sessions to be regular, effective and professional. Areas for improvement The service had identified the need for staff to begin a formal process of reflecting on training accessed and the learning points gained that would be used in practice. It was agreed as part of the continued professional learning for staff reflective practice needed to be developed and that evidence folders needed to be maintained to satisfy SSSC. An area for improvement identified was the need for clear recording to confirm any action taken as a measure to improve staff practice. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Penumbra - Queens Drive, page 19 of 26

20 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 5 - Very 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 Similar to Quality Themes 1 and 2, statement 1. The service currently encourages people to express their views about the quality of Management and Leadership through the various opportunities described in Quality Theme 1, statement 1. We found opportunities including a regular 'managers open hour' encouraging people to talk directly with the manager of the service and we found that managers were involved in communicating with people and their carers to encourage involvement in giving their views about service initiatives. National consultation was evident to gain the views of people in the development of the organisation. Recent consultation had been about Self Directed Support gathering the views of people that used Penumbra services. Areas for improvement The service should consider the areas for improvement highlighted in Quality Theme 1, statement 1. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Penumbra - Queens Drive, page 20 of 26

21 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 Inspection report continued We found that the service was performing at a very good level in this statement. We found that the service responded to complaints through implementation of the policy and procedure. This resulted in people's concerns being dealt with professionally and effectively to ensure that the service was improved where necessary as a result. People that we talked with said that they could raise an issue with staff and that managers would deal with it. Across the service quality indicators were used to measure the quality of the service. They included: Engaging with people to gather their views and measure the quality of outcomes. Six monthly reviews that ensured the care and support details in the personal plan were current. Staff supervision sessions Team meetings Training needs analysis Staff monitoring Audits were undertaken by the service and submitted in a report to the provider. The report included, for example, details of accidents and incidents and complaints. The provider was able to identify trends and take action to minimise risk to people using the service, carers and staff. The organisational strategic plan identified National findings of surveys and identified actions to be taken to improve the services being delivered. We could see how changes were being made across the organisation Nationally, geographically and at a local level. The service had it's development plan identifying improvements to be made giving an overview of the service development. For example personalisation and self directed support were initiatives that were being adopted across all services. We saw minutes of meetings for the 'Quality and Improvement sub-committee' who were working towards the European foundation for Quality Management (EFQM) Excellence Model. Penumbra - Queens Drive, page 21 of 26

22 Areas for improvement Inspection report continued To reach a level of continued quality assurance that involves people using the service, carers, staff and other stakeholders, the service needs to further develop the strategies in place. Examples could be: Implement systems developed that introduce reflective practice for all staff encouraging them to assess their own performance. As identified by the service formal involvement of people using the service in measuring the quality of staff practice. As identified by the service develop current audits of personal plans Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Penumbra - Queens Drive, page 22 of 26

23 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 N/A 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). Penumbra - Queens Drive, page 23 of 26

24 5 Summary of grades Quality of Care and Support Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Environment Very Good Statement 1 Statement Excellent 5 - Very Good Quality of Staffing Very Good Statement 1 Statement Excellent 5 - Very Good Quality of Management and Leadership Very Good Statement 1 Statement Excellent 5 - Very Good 6 Inspection and grading history Date Type Gradings 9 Nov 2011 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed Management and Leadership 5 - Very Good 21 Dec 2010 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed 4 Nov 2010 Announced Care and support 5 - Very Good Environment Not Assessed Staffing 4 - Good Management and Leadership Not Assessed Penumbra - Queens Drive, page 24 of 26

25 25 Mar 2010 Unannounced Care and support 3 - Adequate Environment Not Assessed Staffing 4 - Good Management and Leadership Not Assessed 18 Jan 2010 Announced Care and support 3 - Adequate Environment 4 - Good Staffing 5 - Very Good Management and Leadership 4 - Good 23 Mar 2009 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed 10 Sep 2008 Announced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very 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. Penumbra - Queens Drive, page 25 of 26

26 To find out more about our inspections and inspection reports Read our leaflet 'How we inspect'. You can download it from our website or ask us to send you a copy by telephoning us on This inspection report is published by the Care Inspectorate. You can get more copies of this report and others by downloading it from our website: or by telephoning Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: enquiries@careinspectorate.com Web: Penumbra - Queens Drive, page 26 of 26