Saint John of God Hospitaller Services Housing Support Service Casa Venegas Kirktonfield Road Neilston G78 3NZ Telephone:

Transcription

1 Saint John of God Hospitaller Services Housing Support Service Casa Venegas Kirktonfield Road Neilston G78 3NZ Telephone: Inspected by: Annabell Nicolson Type of inspection: Unannounced Inspection completed on: 20 April 2011

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 6 3 The inspection 11 4 Other information 19 5 Summary of grades 20 6 Inspection and grading history 20 Service provided by: Saint John of God Hospitaller Services Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Annabell Nicolson Telephone enquiries@scswis.com Saint John of God Hospitaller Services, page 2 of 21

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 4 Good Quality of Staffing N/A Quality of Management and Leadership 4 Good What the service does well The service had a positive commitment to person centred care and staff were keen to ensure that individual service users were listened to and had their needs and wishes met wherever possible. Service users were observed to be comfortable and at ease in their interactions with staff. What the service could do better The service could better evidence how consultation with service users, families and staff influenced the future development of the service. The views of other relevant stakeholders could also be sought. More frequent supervision needed to be established for all staff. The written information available about the service needed to be reviewed and include the necessary information about SCSWIS's contact details and its role in relation to complaints. Vigilance in relation to medication and accident/incident procedures should continue. What the service has done since the last inspection The service had introduced new guidelines for staff in relation to head injuries. An analysis of incidents relating to medication administration had been completed for The service had developed a new consultation questionnaire for service users. Saint John of God Hospitaller Services, page 3 of 21

4 Conclusion The service had met the requirement and recommendations made following the last inspection. Interviews and questionnaires confirmed that service users and their families were very happy with the standard of care and support provided. Who did this inspection Annabell Nicolson Lay assessor: n/a Saint John of God Hospitaller Services, page 4 of 21

5 1 About the service we inspected Saint John of God Hospitaller Services was registered with the Care Commission from July Social Care and Social Work Improvement Scotland (SCSWIS) is the new regulatory body for care services and took over the responsibilities of the Care Commission on 1 April The support service is an integrated Housing Support/Care at Home service that supports adults with learning disabilities and physical disabilities within their own homes in various locations in East Renfrewshire. The stated aims of the service are to provide a high quality service based on the needs and wishes of each individual with particular emphasis on promoting independence and encouraging choice. The needs of the people using the service are paramount in the design and delivery of the support. Each package is developed on an individually assessed basis and can range from one or two hours a week to 24 hours a day. 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 Staffing - N/A 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 or by calling us on or visiting one of our offices. Saint John of God Hospitaller Services, page 5 of 21

6 2 How we inspected this service The level of inspection we carried out In this service we carried out a medium intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection This report was written following an announced (short notice) inspection that took place on 14 April 2011 between 10.30am and 5pm and on 20 April between 10am and 1.30pm. In this inspection, evidence was gathered from various sources including the following: The service's most recent self assessment Update of service improvement plan The provider's annual report 2009 The outcome of questionnaires from service users and carers Accident and incident records Medication analysis Staff training records Record of complaints Staff meeting minutes Two support plans Discussions with the Manager and four staff Meetings with three service users 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 Saint John of God Hospitaller Services, page 6 of 21

7 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 Saint John of God Hospitaller Services, page 7 of 21

8 What the service has done to meet any requirements we made at our last inspection The requirement The service must seek medical advice when service users sustain head injuries. This is in order to comply with SSI 114 Regulation 4(1)(a) Providers shall make proper provision for the health and welfare of service users. Timeframe: As appropriate. What the service did to meet the requirement The service had developed a new guidance detailing the action to be taken by staff when a service user sustained a head injury. Examination of accident and incident records confirmed that appropriate medical advice was being sought by staff in most circumstances. A specific incident was however discussed with the Manager during the inspection and, while it was acknowledged that the injury had been the result of a recognised pattern of behaviour, contact with medical personnel would have been advisable. The use of this guidance will be monitored at future inspections and will remain as an area for improvement. (see Quality Statement 1.3, Areas for Improvement) The requirement is: Met What the service has done to meet any recommendations we made at our last inspection Two recommendations were made following the last inspection. 1. The service should carry out an analysis of the incident reports relating to the wrongful administration of medication to service users. The service should produce an action plan based on the findings in order to try to minimise incidents of medication errors. National Care Standards - Housing Support Services, Standard 3.4 Management and staffing arrangements A medication incidents analysis for 2010 had been carried out by the Manager. It identified the main causes of errors, management's response and the learning outcomes. Some sections of the medication procedures were also updated. While the recommendation was met, this will be monitored at future inspections and will remain as an area for improvement. (see Quality Statement 1.3, Areas for Improvement) 2. The service should ensure that all risk assessments relating to challenging behaviour are current and based on individual service users' lives within their own Saint John of God Hospitaller Services, page 8 of 21

9 homes and local community. National Care Standards - Housing Support Services, Standard 3.4 Management and staffing arrangements Risk assessments relating to different aspects of individual service users' lifestyles were seen in support plans. They were up to date and specific to individuals' current circumstances. The involvement of service users and carers was also evident. The recommendation was met. The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The service completed a self assessment before the inspection. It had relevant information for each of the quality statements and identified what it thought it did well and some areas for improvement. Taking the views of people using the care service into account During the inspection, three service users were seen individually in their own home. They spoke warmly about the different staff that supported them and described what they liked to do, for example, their outings with staff and the clubs that they attended. Taking carers' views into account No carers were available during the inspection. Seven carers completed questionnaires on behalf of service users. They all indicated that they were happy with the overall quality of the care and support provided. Some of their comments were: "I am extremely happy regarding the care my relative receives and have great confidence in the way the service is run and the carers and managers who ensure its smooth running" "the carers have a great attitude and are obviously committed to their work of caring" "her home (sister) is always spotless and welcoming to visitors" Saint John of God Hospitaller Services, page 9 of 21

10 "the carers from Saint John of God were fantastic during my sister's stay in hospital" Saint John of God Hospitaller Services, page 10 of 21

11 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 The service had a proactive approach to making sure that service users and carers were encouraged to participate where they wished to and according to need. A consultation day had been held for service users and carers in 2009, and feedback and a report were made available. The service's annual questionnaire had been issued to carers earlier this year. A new section inviting any comments had been added to the form. Responses seen indicated that they were very happy with the quality of care and support provided. Some of their comments were "I am delighted with the standard of care", "the staff are very dedicated to their work", "my relative is getting the absolute best of care and quality of life" and "we are encouraged to speak to staff about any aspect of her (service user) life". A new consultation questionnaire for use with service users had recently been developed by the service. It was detailed and had been designed to take account of service users with significant verbal communication difficulties. Where appropriate, weekly meetings were held with service users individual properties, and minutes were kept. These showed discussion about menu choices for the following week and the activities and outings that service users wished to take part in during their individual time with staff. In support plans sampled, there was good evidence of service users and families being involved in developing and reviewing their support plans and risk assessments. As confirmed in staff interviews, the recent recruitment of two additional staff had significantly reduced the high use of agency staff evident during most of Saint John of God Hospitaller Services, page 11 of 21

12 Areas for improvement The new consultation questionnaire for service users had yet to be implemented. Another consultation event for service users was due to be held. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 3 We ensure that service user's health and wellbeing needs are met. Service strengths Support plans sampled confirmed that staff were supporting individual service users with different activities designed to promote their physical and mental wellbeing. The plans were person centred with service users' preferred daily routines well documented. They also detailed what needed to be in place to keep them healthy and safe. The service had an appropriate accident and incident recording system. Records indicated that staff took appropriate action that included consulting management and seeking medical advice as required. Investigations were also carried out by management in response to specific incidents. There was good evidence that the service had well established links with different health and social care professionals who were invited to reviews of support plans. Minutes of staff team meetings confirmed that service users' care and support needs were routinely discussed. For example, a planning meeting was specifically arranged to discuss in more detail one service user's activities programme. The service's training programme provided courses about different health related topics such as medication, infection control and food hygiene. A number of staff had done training in Non Abusive Physical and Psychological Intervention and also in restraint awareness. Individual risk assessments were detailed and related to different aspects of service users' lifestyles. The involvement of service users and their families, if appropriate, was clearly evidenced. The assessments seen were up to date. Records indicated that service users' weight and nutritional needs were being regularly monitored. As part of the provider's induction training, all staff had completed an autism awareness course. Two staff had also attended an advanced course on autism. There Saint John of God Hospitaller Services, page 12 of 21

13 was evidence that the service was managing complex support needs well, with good recording of the triggers and strategies to be adopted in managing challenging behaviour. Areas for improvement While the service had appropriately responded to the issues previously highlighted in relation to medication administration, this should continue to be closely monitored. Continued monitoring of incidents was also needed. In the self assessment, the annual update on medication procedures was highlighted as overdue for some staff. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 4 We use a range of communication methods to ensure we meet the needs of service users. Service strengths The service's information leaflet had a brief description about its aims and what it provided for service users. Service users' specific communication needs were clearly documented in their support plans. Every service had a named Care Manager who could advocate on their behalf and was routinely invited to all reviews of support plans. Most of the staff had attended different training related to service users' communication needs including 'Intensive Interaction' and 'Total Communication'. All staff had also completed training on a communication system that was being used by a service user who had autism. Pictorial based systems had been used on the consultation day and were also in use for some service users' daily routines. The most recent inspection report was displayed at the service's office base. The organisation had a pictorial complaints procedure and form. Areas for improvement The service needed to consider how the outcome of inspections and the availability of reports could best be communicated to service users and their families. The service's plan to develop an information pack was welcomed as the current Saint John of God Hospitaller Services, page 13 of 21

14 written information available is limited. The complaints procedure was not detailed in the service leaflet and there was no information available about the contact details of the regulating body and its role in complaints. (see Requirement 1) As indicated in the self assessment, the service was intending to adopt a similar format to the new service users' consultation questionnaire when preparing for reviews of support plans. Grade awarded for this statement: 4 - Good Number of requirements: 1 Number of recommendations: 0 Requirements 1. The service's complaints procedure must include the name and address of SCSWIS and provide information about how complaints can be made to SCSWIS about the service. This is in order to comply with SSI 2011/210 Regulation 18 (6)(a) and (6)(b) Complaints Timescale for implementation: Within six months of the issuing of this report Saint John of God Hospitaller Services, page 14 of 21

15 Quality Theme 3: Quality of Staffing - NOT ASSESSED Saint John of God Hospitaller Services, page 15 of 21

16 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 4 - Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths The evidence in relation to consultation and participation in Statement 1.1 is relevant to this Statement. The questionnaire used for carers had a few specific questions asking for their views about the management team. The addition of a 'comments' section in the questionnaire and attendance at annual reviews provided opportunities for them to give their views and comments about the management of the service. In the most recent survey undertaken with carers, no issues were noted in the responses received. Areas for improvement As noted in Statement 1.1, a consultation event for service users was due to take place. The service needed to consider how the outcomes of the different consultations undertaken with service users and carers could be taken into account in the completion of the self assessment. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Statement 3 To encourage good quality care, we promote leadership values throughout the workforce. Service strengths With the departure of the present Manager imminent, two existing Senior staff had been identified as suitable candidates to assume responsibility for the management role. The service had an annual training programme that offered a range of mandatory and developmental courses for staff. Staff interviewed described opportunities for training as very good and as relevant to the needs of service users. Saint John of God Hospitaller Services, page 16 of 21

17 Senior staff had individual management responsibilities as well as ones that were shared. In addition to their responsibilities as key workers, individual support staff had specific responsibility for other areas including Health & Safety and fire safety in each property. Staff teams were responsible for organising shifts and allocating tasks. The majority of staff had a relevant qualification. Senior staff had successfully completed SVQ 4 while support staff were trained to Level 3 with the intention of providing them with the potential skills to consider a more responsible role in the future. Six staff were in the process of completing SVQ. Experienced staff were identified as mentors when new staff were appointed. Areas for improvement As noted at the previous inspection and in the self assessment, the service's aim for quarterly one to one supervision for all staff had not been achieved. As a consequence, annual appraisals were not being undertaken. The service needed to focus on establishing more regular supervision for all staff. While there was a good training calendar in place, it was noted that a number of staff had not completed all training identified as mandatory by the service. This included Infection Control and the Protection of Vulnerable Groups. The frequency of meetings for individual staff teams varied, and minutes indicated that discussion mainly focused on individual service users and tasks. The service should consider the possibility of arranging meetings that would give the full staff team the opportunity to participate in discussions about the future development of the service. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide Service strengths There were different ways in which service users' and carers' views and suggestions were sought. This included consultation days, questionnaires and individual reviews that involved representatives from external agencies at least annually. They were also encouraged to take part in the inspection process. It was clear that management was visible and accessible and committed to maintaining positive relations with service users and their families. Saint John of God Hospitaller Services, page 17 of 21

18 The service had a copy of the corporate annual report for The next one is expected in September The service improvement plan had been updated in October Monthly audits of medication, finances and health and safety checks were undertaken in individual properties. Where appropriate, service users would be involved. The service submitted actions plans in relation to recommendations and requirements made following inspections. As appropriate, notifications of incidents were also made. Areas for improvement It was not clear how the views of service users, carers and staff informed the service improvement plan. Management advised that new Health & Safety self assessment documentation was being introduced by the provider. Consideration should be given to developing a system for obtaining the views of key stakeholders that would be taken into account in the evaluation of the service. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Saint John of God Hospitaller Services, page 18 of 21

19 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). Saint John of God Hospitaller Services, page 19 of 21

20 5 Summary of grades Quality of Care and Support Good Statement 1 Statement 3 Statement Very Good 5 - Very Good 4 - Good Quality of Staffing - Not Assessed Quality of Management and Leadership Good Statement 1 Statement 3 Statement Good 4 - Good 4 - Good 6 Inspection and grading history Date Type Gradings 6 May 2010 Announced Care and support 4 - Good Staffing 4 - Good Management and Leadership Not Assessed 7 Jul 2009 Announced Care and support 5 - Very Good Staffing 5 - Very Good Management and Leadership 4 - Good 14 Nov 2008 Announced Care and support 3 - Adequate Staffing 3 - Adequate Management and Leadership 3 - Adequate All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Saint John of God Hospitaller Services, page 20 of 21

21 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: Saint John of God Hospitaller Services, page 21 of 21