John Street House Care Home Service Adults 38 John Street Kirkintilloch Glasgow G66 2HE Telephone:

Transcription

1 John Street House Care Home Service Adults 38 John Street Kirkintilloch Glasgow G66 2HE Telephone: Inspected by: Roddy MacInnes Type of inspection: Unannounced Inspection completed on: 28 April 2012

2 Contents Page No Summary 3 1 About the service we inspected 4 2 How we inspected this service 5 3 The inspection 9 4 Other information 17 5 Summary of grades 18 6 Inspection and grading history 18 Service provided by: East Dunbartonshire Council Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Roddy MacInnes Telephone enquiries@scswis.com John Street House, page 2 of 20

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 N/A Quality of Environment 5 Very Good Quality of Staffing 5 Very Good Quality of Management and Leadership N/A What the service does well The service offers a caring and person centred support system. Support is individualised and targeted according to individual abilities What the service could do better The service needs to continue to improve its strategies for involving all stakeholders in the assessment and improvement of the service, and to monitor those systems already in place for effectiveness. What the service has done since the last inspection Staff have continued to arrange meaningful activities for service users to participate in. Conclusion Documents confirmed that the service has continued to develop in all areas. In conclusion, the service is committed to supporting its service users to meet their potential. Who did this inspection Roddy MacInnes John Street House, page 3 of 20

4 1 About the service we inspected John Street House is a Care Home situated in a residential area in Kirkintilloch. The service provides physical, emotional, intellectual and social supports to eleven adults who have a learning disability. The Home is managed by East Dunbartonshire Council. The accommodation is purpose built and has level access to all rooms. There are two living/dining rooms, a central communal room, eleven en-suite bedrooms, a main kitchen and two smaller kitchen areas. A laundry area provides space for those service users who are capable of attending to their own washing/ironing. There is a large landscaped garden at the rear of the property with a designated seating area. A current re-decoration programme has enhanced the overall environment which is welcoming and comfortable. The aim of John Street House is to provide "a safe and homely environment to live in trained and experienced staff... support to achieve increased independence the opportunity to use community facilities support to develop and maintain local supports and friendships the opportunity to integrate with the community." The Care Inspectorate (SCSWIS) is the new regulatory body for care services in Scotland. It will award grades for services based on the findings of inspections. The history of grades that services were previously awarded by the Care Commission are also available on the SCSWIS website Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - N/A Quality of Environment - Grade 5 - Very Good Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - N/A 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. John Street House, page 4 of 20

5 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 this report following an unannounced inspection that took place over two periods starting on 20/04/12 between 6.30pm to 8pm. The inspection concluded on 28/04/12 starting at 5.30pm with feedback to the manager ending at 9.15pm. The inspection was carried out by care inspector, Roddy MacInnes. As requested by us, the care service sent us an annual return. The service also sent us a self assessment form. In this inspection we gathered evidence from various sources, including the relevant sections of policies, procedures, records and other documents including: * evidence from the service's recent self assessment * 3 support plans of service users * registration certificate * 5 Workers interviewed * 5 service users * Notice Boards * Updated daily, weekly routines which have importance for service users relating to daily living * risk assessments * Observation of 1 group activity * the manager * senior from the management team * minutes of key work and review meetings that the service users took part in * 1 questionnaire returned to the Care Inspectorate * service user meetings * Observation of how staff work * Previous 3 months staff team minutes * Previous 3 months management team minutes * Previous 3 service user's minutes * Recent carers letters * organisational audits * Training plans for 2012 John Street House, page 5 of 20

6 * Activities records and plans with clear involvement with service users * Service's participation information Grading the service against quality themes and statements We inspect and grade elements of care that we call 'quality themes'. For example, one of the quality themes we might look at is 'Quality of care and support'. Under each quality theme are 'quality statements' which describe what a service should be doing well for that theme. We grade how the service performs against the quality themes and statements. Details of what we found are in Section 3: The inspection Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at John Street House, page 6 of 20

7 What the service has done to meet any recommendations we made at our last inspection Examination of relevant paperwork confirmed that four of the five recommendations made at the last inspection had been full met. The staff team had worked hard to improve their record keeping and documentation since the last inspection. Quality assurance systems have been developed to be more effective. The one recommendation which has been repeated within this report relates to the Management and staff seeking further ways in which service users can be involved in the assessment of the quality of management and leadership using where appropriate external supports. The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self assessment document from the service provider. This was completed to a high standard and highlighted the strengths of the service whilst also highlighting meaningful areas of improvement. Taking the views of people using the care service into account All people using this service were very positive about the support which they received from the service. Five service users were spoken with during this inspection. Questionnaires returned to the Care Inspectorate were very positive. Comments from service users during this inspection included: "staff have been very helpful" "staff are always nice to me" "I have a nice key worker" "I get to go on holidays" "I know my key worker" "I like my centre" John Street House, page 7 of 20

8 Taking carers' views into account Inspection report continued No carers were available during this inspection. Recent records held by the service indicated a high level of satisfaction. Comments included: "very happy and contented" "all appear happy, healthy & content" staff have been great, always there if you need them and very helpful" "very high standard" "all aspects of...care are is dealt with very professionally" "warm atmosphere within the house" John Street House, page 8 of 20

9 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 - NOT ASSESSED John Street House, page 9 of 20

10 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 An examination of relevant documents and feedback from service users, staff and managers indicated a very good performance by the service in relation to this statement. All service users have support plans which are updated on a regular basis. There is a more comprehensive review of support every six months. All support plans and risk management plans are signed by the service user following implementation and subsequent reviewed to show agreement. In turn these plans are regularly audited by the manager of the service as a further quality assurance mechanism. The personal plans which were examined were seen to have been updated regularly and recorded comprehensively. There had been obvious dialogue which took account of the service user's changing needs and the personal plan amended accordingly. The premises offer a homely and comfortable environment for service users to live. The premises are warm and clean and are decorated and maintained to a high standard. The service contains pictures and other items which are meaningful to service users. There are rooms that service users can access and the relaxed environment enhances their quality of life. Service users confirmed that they were very comfortable in the home, with nice bedrooms, which they have personalised and keep private, as they choose. Rooms are observed by the inspector to offer a private, homely space for service users to relax in. We saw the minutes of service user's meetings which are held regularly. These meetings cover all aspects of the home which are relevant to service users. These include environmental developments, functions, activities, menus and how the home can improve upon support provided. Service user's rooms were seen to be lockable, and decorated according to the service user's taste. John Street House, page 10 of 20

11 Areas for improvement The Manager was aware that existing systems of quality assurance which include service user and carer participation in evaluating all aspects of the service should be developed further. Consideration should be given to evidence the involvement of service users and their family members or advocates, where appropriate, in the completion of the self assessment and inspection grading. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. Consideration should be given to evidence the involvement of service users and their family members or advocates, where appropriate, in the completion of the self assessment and inspection grading. National Care Standard Number 5: Care Homes for People with Learning Disabilities John Street House, page 11 of 20

12 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths Following consideration of sampled written evidence, and feedback from management, staff and service users, this service has a very good performance in relation to this statement. Records of the service examined indicated that the service were complying with the relevant legislation and guidance with regard to fire, health and safety procedures and risk management. For example there were regular fire drills and risk assessments of the premises and for outings. Service users confirmed that their opinions were sought regarding issues about the environment. One service user commented: ' It's a nice place.' Service users have control over who enters their personal space, all bedroom and toilet doors have a lock and staff knock and request permission before entering. Staff respect service users right to dignity and provide personal support in a sensitive manner. Key workers and staff assist service users to maintain their personal property, ensuring they have appropriate supplies as required. The service makes effective use of different ways of informing people and involving them in the life of the service, for example a notice board, newsletters and displaying inspection reports. Notice boards were all updated on a planned basis and helped to ensure that service users were kept informed of developments. The outcome of this is that service users know what to expect and are well-informed about any changes relating to the environment which affect them. They are also in a better position to comment on how well the service meets certain standards and expectations. Areas for improvement There were no areas identified during this inspection as the service continued to make improvements in this area. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued John Street House, page 12 of 20

13 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 An examination of relevant documents and feedback from service users, staff and managers indicated a very good performance by the service in relation to this statement. Questionnaires issued to service users and carers have questions relevant to staff performance. The outcome of these questionnaires shows a good level of satisfaction with staffing within the service. Personal Development Plans examined reflected preferences and choices with Key Workers offering support through assistance with shopping and daily living. Interviews with staff and examination of service user's files indicated that Key Workers helped service users by advising them on nutritionally balanced meals that reflected their dietary needs. Personal Development Plans of each service user indicated that a comprehensive assessment was undertaken and reviewed regularly with the service user, their social worker and Key Worker being involved. These assessments and reviews centred around the social, psychological and health needs of each service user and this was recorded in the personal plans with action plans to meet these needs. Staff confirmed that individual supervision takes place on a regular basis and confirmed this was beneficial to their work practise. Risk management and health and safety systems were in place. Medication procedures are in place and staff demonstrated that these were being implemented. Areas for improvement The service should consider further developing their participation strategy, which would provide service users and carers with a written commitment to involving them in assessing and improving the quality of the management and leadership within the service. The service should then train staff in how to implement the participation strategy. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 John Street House, page 13 of 20

14 Recommendations Inspection report continued 1. Management and staff should seek further ways in which service users can be involved in the assessment of the quality of management and leadership using where appropriate external supports. National Care Standard 5 Care Homes for People with Learning Disabilities - Management and Staffing Arrangements John Street House, page 14 of 20

15 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths An examination of relevant documents and feedback from service users, staff and managers indicated a very good performance by the service in relation to this statement. As highlighted in previous inspections, the staff team were experienced in the provision of care and support to the people they supported. Care plans and assessment documents had continued to be improved. There was a staff appraisal and continuing professional policy in use. Service users confirmed that they understood about complaints and who to complain to. The staff team confirmed that where possible service users were encouraged to contribute to the care planning process and were supported to meet their own identified goals. Regular reviews took place for all service users. Risk assessments were examined in care plans and were up-to-date. Case records were found to be accurate and factual. They were clearly laid out and were easily accessible for service users to fully participate in all aspects of care planning Areas for improvement There were no areas identified during this inspection as the service continued to make improvements in this area. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued John Street House, page 15 of 20

16 Quality Theme 4: Quality of Management and Leadership - NOT ASSESSED John Street House, page 16 of 20

17 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 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). John Street House, page 17 of 20

18 5 Summary of grades Quality of Care and Support - Not Assessed Quality of Environment Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Staffing Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Management and Leadership - Not Assessed 6 Inspection and grading history Date Type Gradings 24 Dec 2011 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed Management and Leadership 5 - Very Good 26 Jan 2011 Unannounced Care and support 6 - Excellent Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed 23 Jul 2010 Announced Care and support 6 - Excellent Environment Not Assessed Staffing Not Assessed Management and Leadership 5 - Very Good 16 Mar 2010 Unannounced Care and support 6 - Excellent Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed John Street House, page 18 of 20

19 26 Nov 2009 Announced Care and support 6 - Excellent Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed 11 Nov 2008 Announced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good 20 Mar 2009 Unannounced Care and support 6 - Excellent Environment 6 - Excellent Staffing Not Assessed Management and Leadership Not Assessed All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. John Street House, page 19 of 20

20 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 SCSWIS. 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@scswis.com Web: John Street House, page 20 of 20