Carr Gomm - East & Midlothian Housing Support Service 8 The Loan Loanhead EH20 9AF Telephone:

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1 Carr Gomm - East & Midlothian Housing Support Service 8 The Loan Loanhead EH20 9AF Telephone: Inspected by: Stephen Ball Type of inspection: Announced (Short Notice) Inspection completed on: 28 October 2013

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 12 4 Other information 27 5 Summary of grades 28 6 Inspection and grading history 28 Service provided by: Carr Gomm Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Stephen Ball Telephone enquiries@careinspectorate.com Carr Gomm - East & Midlothian, page 2 of 30

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 4 Good Quality of Management and Leadership 4 Good What the service does well The service works well to involve service users in the design and delivery of their support packages and that of the development of the services. The registration of this service includes five separate services across three local authorities and we saw evidence that the service provider works well to bring consistency in terms of the assessment of needs, support plans, support protocols and other related documents. Service users we met with spoke highly of the experiences of using the service and felt involved in every aspect of their support delivery. The service works well with external support agencies including that of health professionals and social workers. What the service could do better Although not across all services, we were made aware of some staffing issues which had a detrimental effect on service users following discussions with them and staff. This has given us cause for concern. Management oversight and leadership direction at the supported accommodation services is also a concern and we have highlighted these areas further within this inspection report. Carr Gomm - East & Midlothian, page 3 of 30

4 Whilst we were satisfied that positive outcomes are being achieved for the large majority of service users, the service would benefit from evidencing this more, especially at the six monthly formal reviews. Again we have highlighted this further within this report. What the service has done since the last inspection We made a number of requirements and recommendations at the last inspection, mainly focusing on staff training and support delivery protocols. The service provider has worked well to achieving the high standards in these areas. We have commented on this further within this report. Conclusion Based on the evidence available to us Carr Gomm is providing a valuable support service to service users and this is echoed by those we spoke with. There are however some concerns with regards to the management oversight at two of the supported accommodation services. In addition, there are some support practices which also should be addressed. The areas we have identified for requiring improvement or further development have been highlighted by the requirements and recommendations included within this report. Who did this inspection Stephen Ball Carr Gomm - East & Midlothian, page 4 of 30

5 1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Prior to 1st 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. Carr-Gomm Scotland Mid and East Lothian is registered with the Care Commission to provide a combined housing support and care at home service. Support is provided to adults with a wide range of needs living in their own homes or in shared accommodation. Carr-Gomm Scotland Mid and East Lothian is made up of the following individual services: 1. Cameron Cottage, a residential support service located in Musselburgh. 2. Park Cottage, again a residential support service located in Newtongrange. 3. Visiting support for East Lothian, operating from the local office in Haddington. 4. Visiting support for Midlothian, based in Loanhead. 5. Housing support and care at home in Galashiels in the Scottish Borders. The type of support that each individual receives is detailed and reviewed through a personal planning process. The number of hours support that people receive varies. There is a 24 hour on call service which some people being supported can use. At the time of the inspection there were 165 people being supported by the service. Carr Gomm - East & Midlothian, page 5 of 30

6 The majority of people living in shared accommodation have been referred by local psychiatric hospitals. Service users normally live at the service for approximately a year with the aim of moving to more independent accommodation where appropriate. Each team is managed by a service manager and has a local staff base. All service managers report to the operations manager (the named manager for the service), who works from the staff base in Midlothian. Carr-Gomm Scotland is a national provider which has a number of similar services across Scotland. The organisation's headquarters is in Edinburgh. Carr-Gomm Scotland states that its aims are as follows: "To help people in Scotland live in their own homes, in a safe way, to do things that they want to and to try new things". For the purposes of this report, Carr Gomm is the services operated in Midlothian, East Lothian and The Scottish Borders only. Further Carr Gomm services operate in Scotland, however are not part of this registration with the Care Inspectorate and therefore are reported on by us under separate registration and inspection reports. 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 - Grade 4 - Good Quality of Management and Leadership - Grade 4 - Good This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. Carr Gomm - East & Midlothian, page 6 of 30

7 2 How we inspected this service The level of inspection we carried out In this service we carried out a high 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 We wrote this report following a short notice announced inspection. The inspection was carried out by Inspector Stephen Ball. The inspection took place over the course of five days between the 1st and 10th of October Due to annual leave of the service manager and the inspector, the feedback meeting to the service was slightly delayed until the 28th October. Any immediate concerns identified from this inspection were reported to the manager during this period. As part of this inspection, we took account of the completed annual return and selfassessment forms that we asked the provider to complete and submit to us. We sent 45 care standards questionnaires to the manager to distribute to service users, relatives and carers. We received 20 completed questionnaires prior to the inspection. We also asked the manager to give out questionnaires to staff and we received five completed questionnaires. During this inspection process, we gathered evidence from various sources, including the following: We looked at: * The service user participation strategy. * Business development plans. * Minutes of service user meetings. * Minutes of staff meetings. * A sample of 38 care and support plans and reviews across the five services. * A sample of 27 staff support and supervision meetings across the five services. * A sample of incident and accident reports * Any complaints the service had received * Relevant quality assurance information * Service improvement and development action plans * The environment of the service * Newsletters * Collated the responses from questionnaires issued to service users, carers and Carr Gomm - East & Midlothian, page 7 of 30

8 relatives. We spoke with the registered manager of these services throughout the inspection process. In addition, we spoke with: Park Cottage: * The service manager (joint manager with Cameron Cottage). * Four service users. * Four support staff. Cameron Cottage * The service manager. * Four service users. * Four support staff. Visiting support service in Midlothian * The service manager. * Three support staff. * Four service users. Visiting support service in East Lothian * The acting service manager. * Four service users. * Two carers / family members. * Three support staff. The Borders support service * The service manager. * One support worker. * One service user (others declined to speak to us). * Two health professionals who work closely with the support service. We also attended a service user cooking class in the evening at Cameron Cottage, to be able to interact with people using the service and obtain their views of the care and support they received. 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 Carr Gomm - East & Midlothian, page 8 of 30

9 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 Carr Gomm - East & Midlothian, page 9 of 30

10 What the service has done to meet any requirements we made at our last inspection The requirement The service provider must ensure that staff are appropriately trained in Adult support and protection for the safeguarding and wellbeing of service users. This is to comply with the Scottish Statutory Instruments (SSI) 2011 No 210, Staffing, 15.(a) Timescale: Within an 8 week period on receipt of this report. What the service did to meet the requirement Since our last inspection of the service the service provider has implemented adult support training to all staff to a good standard. The requirement is: Met - Within Timescales The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. We received a fully completed self assessment document from the service provider. We were satisfied with the way the service provider had completed this and with the relevant information they had given us for each of the headings that we grade them under. The service provider identified what they thought they did well, some areas for development and any changes they planned. Taking the views of people using the care service into account We sent out 45 care standard questionnaires to people using the service, relatives and carers. 20 were returned to us. Carr Gomm - East & Midlothian, page 10 of 30

11 Positive comments made included: "I am very happy with the staff and service. The staff work very hard to support us". "I think the care here is wonderful". "I am happy and overall no complaints". "A good service is provided. Good back office support is provided. Staff turnover over the past few months appears to be high and as such I have lost the names of the care team members. I think a list of names should be provided / maintained as part of the support agreement". Some raised particular issues: * One person was not aware of the complaints policy for the service. * Four people did not know how to make a complaint to the Care Inspectorate. Taking carers' views into account "I have been extremely happy with the care my, mother has been receiving. Continuity with the same regular support staff has been invaluable as we have been able to form a good working relationship with them. As a retired health professional myself I am very particular in the level of care my mother receives and Carr Gomm provide this. Inevitably problems can occur but I much appreciate the way they look for solutions rather than dwelling on the problem. We have a good two way dialogue (with the service)". "I have no direct complaints regarding the service of support. However as the support and care service moves forward there seems to be a need for ideas of what to do with the people supported. By that I mean we (both staff and support team) struggle to identify events and things to do during the support hours...". Carr Gomm - East & Midlothian, page 11 of 30

12 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 Carr Gomm has a number of meaningful methods in place to ensure service users have an opportunity to be actively involved in the design, assessment and improvement of the quality of service they receive. Information on these opportunities available, including that of the complaints procedures are detailed within the service user handbook, which all receive when they start using the support service. In addition to the information contained within the handbook, Carr Gomm have a full time involvement officer, whose primary role is to obtain feedback from service users and stakeholders to support the development and strategic direction of services. The options available to service users and their carers include the following: * Service user and carer satisfaction surveys. * Involvement in staff recruitment. * Providing feedback to the management of the service with regards to the performance of the support staff, as part of the staff member's annual performance assessment. * Invited to attend the annual general meeting and have a voice about the future development of Carr Gomm. * Their attendance at local forum meetings. * Discussions held at the six monthly review meetings of their support packages. We looked at some of the evidence available to us in relation to these opportunities for people to be involved. A recent service user satisfaction survey had been completed and people were asked Carr Gomm - East & Midlothian, page 12 of 30

13 to give their views on the following key areas of their support: 1. I would feel comfortable saying if something was bothering me. 2. The people who work with me understand my needs. 3. I am involved in decisions about my support. 4. I am satisfied with the way the service is managed and organised. 5. I feel my service provides what I hoped it would provide. The large majority of responses were very positive and any areas where service users had reported any issues were addressed and replied to on an individual basis. A review was being completed by a local authority for one of the supported accommodation services we visited and the views of people using the service were being gathered, with additional support from advocacy support services where relevant to people's needs. Comments from the service users included: "It's been absolutely brilliant. The staff work very hard and they do a great job". "It has been good to get to know everyone here. I would not change anything and I am happy with what I have got here". We saw evidence of monthly involvement meetings being held, focusing on the findings of satisfaction surveys, the actions required for further improvement, activities and events service users would like to attend. This we assessed to be a very good strength for this statement. At the shared accommodation services, regular service user meetings are held. We sampled some of the notes taken from these meetings and were of the view that service users had an active role in these meetings and were able to make suggestions for improvement. We looked at any complaints the services had received since our last inspection. We were told that three `informal` complaints had been received. Evidence available to us told us that these complaints had been addressed in line with the complaints policy. Areas for improvement At our last inspection of the service, we made the recommendation for the service provider to re-issue information about the complaints procedures and how people can also complain to the Care Inspectorate. This was due to the number of people who were not familiar with the process of making a complaint. Although we saw evidence at Park and Cameron Cottages that this had been done, five out of the 45 returned questionnaires to us told us that they did not know the relevant procedures. Although we are not repeating this recommendation at this inspection, the service provider Carr Gomm - East & Midlothian, page 13 of 30

14 should be mindful to provide information on the complaints procedures on a semiregular basis to ensure it is fresh in people's minds. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths With regards to the policies and procedures operated by this service, we referred to our findings at the last inspection. We spoke with the manager to inspect any new or reviewed policies and procedures since our last inspection and these were taken into account this year. The newly revised procedures included that of the management of challenging behaviour, including risk assessing. We found these procedures to be operating relatively well. The service provider worked well to bring consistency across all areas of the service in relation to the assessment of needs and support planning processes. We sampled a total of 38 care and support plans across the five services we inspected and found the content of these documents to be very good. The assessment of needs lead to the design and implementation of an agreed support plan with the service user. Each support plan focusing on their desired outcomes was individually detailed with risk assessments undertaken where relevant. A number of support plans contained detailed support protocols, thus bringing consistency to the delivery of the care and support agreed with the service user. Examples included protocols of what support staff should do if a service user refuses to take their prescribed medication and the health professionals they could contact in such situations. Our assessment following the inspection of the services told us that the support staff were very familiar in the care and support needs of the people who used the service. When speaking with some of the service users we met, a number were undertaking voluntary work or education in their community and support was in place by Carr Gomm to support people to achieve their aspirations. During the course of the inspection, we visited the cooking group taking place at Cameron Cottage one evening, with the purpose of speaking with service users and Carr Gomm - East & Midlothian, page 14 of 30

15 observing the interaction between service users and support staff, which was very positive. The large majority of service users we spoke with were very happy with the support provided and were positive in their views of the support staff. We were told that small support teams provided support to individuals, again bringing consistency in support delivery. At the last inspection of the services we made a requirement and recommendation in relation to more robust policies, procedures and training in relation to adult support and protection awareness and the management of challenging behaviour. Evidence at this inspection tells us that the service provider has worked well to achieve this. Where service users display any identified challenging behaviour support needs, effective and easy to follow protocols are in place for staff to follow. For example; at the supported accommodation services and that of the service in the Scottish Borders, a traffic light system for defining what level of intensity in terms of support had been agreed with the service and other relevant parties, including that of health professionals. Service users at the Borders service declined to speak to us as part of the inspection so we spoke with two health professionals who the service works very closely with. The health professionals spoke very highly of the newly established service in Galashiels and felt the service was meeting the needs of service users to a very high standard. They also felt the staff were well trained and the service was managed well. Due to the nature of the service in the borders, weekly joint meetings are held between health professionals and the management of the service, for which we sampled some of the evidence available to us. The majority of support plans across the five services had been reviewed on a six monthly basis. The process of the reviewing of the support plans was to update and agree the support plan with the service user. We also saw evidence of six weekly reviews of peoples outcomes and whether they were being achieved with the support from staff. We looked at the entire incident records and identified no concerns with the health and safety of people who use the services. The majority of incident records focused on behaviour related issues for which were managed well by the support staff. Areas for improvement During our inspection visit at the Parks Cottage, we observed the interaction between service users and staff, and explored with service users what their typical week included in terms of activities and other areas of outcome planning. Following our observation and discussions with some of the service users, we assessed that some were struggling to fill their time during the day and had a sense of feeling bored with a lack of activities to undertake. Although this was not the case for all, it was for Carr Gomm - East & Midlothian, page 15 of 30

16 some. The service provider should therefore work with service users to identify more meaningful activities within their local community. Upon inspection of the care and support plans at the Parks Cottage, we identified three out of the six support plans had not been signed and agreed by the service user and provider. To meet current best practice, as detailed in the National Care Standards, all support plans should be signed and agreed by the service user (when capacity is available) or by another identified individual on their behalf. We are therefore making this a recommendation. Please see recommendation 1. When we looked at the review of support plans across the service, the process was to update an agreed support plan. However this procedure did not capture and evidence the discussions held between the service user and provider and what actions had been agreed. We saw evidence of previous practice where this had been done and the discussions held at the review stage were recorded. Although we saw clear evidence that the large majority of support plans were being reviewed on a six monthly basis to meet current legislation, recording the review meetings in this way would bring added benefit to the service. When we inspected the visiting support service in Midlothian, we identified that four support plans had not been reviewed for over six months. We discussed our findings with the manager of the service who informed us that the service users were scheduled to leave the service and did not see the benefits of reviewing the support plans. However some time had lapsed and we discussed with the manager that all support plans should be reviewed whilst people are using the service. We are however not making this a recommendation or requirement as we are confident that the usual practice is to undertake the six monthly reviews. We sampled the risk assessments belonging to service users and although they identified the potential risks of each of the assessed and agreed areas of support, we identified that the risk assessment process could be further developed. For example, to risk assess the mobility, moving and handling of service users and for this to be reviewed on a six monthly basis. We are therefore making this a recommendation. Please see recommendation 2. When we inspected the visiting support service in East Lothian, we saw a support plan which had detailed support protocols in relation to supporting a service user who was under adult support and protection. We discussed this element of the support plan with the acting service manager, who advised us that this adult support and protection was no longer in place. However the support plan had not been updated to reflect this and protocols were still present. The service provider should ensure that support plans remain up to date to reflect any changes in the support to people. We are therefore making this a recommendation. Please see recommendation 3. We looked at some of the records in place for when support staff administer Carr Gomm - East & Midlothian, page 16 of 30

17 medication to service users. Although we found no concerns at the majority of services, we did at the supported accommodation services. Gaps were present in the recording of medication administered by staff and medication errors were not being recorded. The concerns had been identified and highlighted by the manager and discussed at staff meetings. The medication policy belonging to the service provider states that errors should be recorded as incident reports; however we did not see any evidence of this at the inspection. The service provider must ensure that all medication errors are minimised and when they do occur, to have robust recording systems in place. We are therefore making this a requirement. Please see requirement 1. The service provider should also provide clarity on the recording of medication as to whether the staff are administering prescribed medication or simply reminding a service user to take their medication as there are clear differences in terms of the responsibilities involved. We are linking this area of development to requirement 1. Service users are often supported to manage their budgeting and therefore keep financial records of service user's finances. We looked at a sample of these records and although the large majority of records were managed well, we did identify some concerns with the level of recording at the service located in the Borders. Although support staff sign to say money has been withdrawn for legitimate and agreed reasons with the service user, we identified gaps in the signing of records by service users. Although some service users may lack capacity in signing, the service provider should ensure that adequate safeguarding and safety of recording systems are in place. We are therefore making this a recommendation. Please see recommendation 4. As part of our inspection at Cameron Cottage, we explored with the manager and support staff some of the staffing issues which have been occurring in recent weeks. Following these discussions, we identified other concerns with regards to staff performance and management which has had a detrimental effect on some of the service users using the service. We were made or were already aware of the following concerns: * A staff member lending money to service users. * Issues around staff and service user professional boundaries and appropriate and professional behaviour. * A staff member being assaulted by a colleague in the presence of service users. * Concerns over the adult support and protection of vulnerable adults using the service. * Concerns over the health and safety of the environment of the service. * Six occasions recorded when staff have shown a lack of dignity and respect to service users. Although the service provider has taken appropriate actions to address some of these Carr Gomm - East & Midlothian, page 17 of 30

18 concerns, it does give the Care Inspectorate cause for concern in terms of the management and leadership of the support provided at both Cameron and Park Cottages. The manager is spread across the two services and there are no back up procedures in relation to a team leader role of someone who acts up to the management level. Evidence seen tells us that the staff teams at the two services make their own decisions when the manager is on leave. We have referred to this further within statement 4.4 of this inspection report. We read some of the performance reports the visiting support service provides to Midlothian Council. We identified that three care at home visits had been missed by a staff member, which totalled 14 hours. The management of the service were not aware of these missed visits until after they had occurred. Given that some vulnerable adults who use the service may require their medication to be administered or have limited communication abilities, the service provider should explore what systems could be in place to identify missed visits as quickly as possible, to allow for the management to put appropriate cover in place, especially for those service users who rely on the care and support to be provided at a specific time. Please see recommendation 5. Grade awarded for this statement: 4 - Good Number of requirements: 1 Number of recommendations: 5 Requirements 1. The service provider must ensure that all medication errors are minimised and when they do occur, to have robust recording systems in place. This is to comply with the Scottish Statutory Instruments (SSI) 2011 No 210, Welfare of users. Timescale: 28 days from receipt of this inspection report. Recommendations 1. The service provider should ensure all support plans / agreements are signed and agreed by the service user (when capacity is available) or by another identified individual on their behalf. National Care Standards, Housing Support, Standard 4 - Housing Support planning. 2. The service provider should further develop their process of undertaking risk assessments with service users to be more robust. National Care Standards, Housing support, Standard 3 - Management and staffing arrangements. Carr Gomm - East & Midlothian, page 18 of 30

19 3. The service provider should ensure that support plans remain up to date to reflect any changes in the support to people. National Care Standards, Housing Support, Standard 4 - Housing Support planning. 4. The service provider should ensure that adequate safeguarding and safety of recording systems are in place for record keeping of finances belonging to service users. National Care Standards, Housing Support, Standard 3 - Management and staffing arrangements. 5. The service provider should explore what systems could be in place to identify missed visits as quickly as possible. National Care Standards, Care at Home, Standard 4 - Management and staffing. Carr Gomm - East & Midlothian, page 19 of 30

20 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 4 - Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths Statement 1.1 has been taken into account for this statement. Across all of the services, systems are in place to allow for service users to provide their views on the individual staff who support them. This level of feedback, usually through completed questionnaires forms an element of the staff member's annual appraisal. This we saw to be a key strength for this statement. We also were told that there have been occasions when service users have been involved in the recruitment of support staff; however we did not see evidence of this at this inspection. Areas for improvement Statement 1.1 has been taken into account for this statement. The service provider should further develop the existing process as detailed above in terms of providing opportunities for service users to participate in assessing and improving the quality of staffing. When we inspected some of the service user files and staff support and supervision records, we identified a number of staff performance issues which had been reported by service users or their carers. We are of the view that these concerns were received and recorded as informal complaints. The service provider should however record all concerns from service users and carers about the performance of staff as formal complaints and adhere to the complaints procedures in this regard. We are therefore making this a recommendation. Please see recommendation 1. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 Carr Gomm - East & Midlothian, page 20 of 30

21 Recommendations 1. The service provider should record all concerns from service users and carers about the performance of staff as formal complaints and adhere to the complaints procedures in this regard. National Care Standards, Housing Support, Standard 8 - Expressing your views. Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths The service provider has a staff support and supervision policy in place, which details the aims and objectives of staff meeting with their line manager three times a year, in addition to their annual appraisal. We spoke with 20 staff to explore how well they felt supported within their roles and how the morale was amongst the team. All those spoken with informed us that they felt supported by their manager and felt they could approach the management at any time. The morale amongst the majority of services was positive. We sampled a total of 27 staff files across the five services we inspected. All of those sampled contained a record of the staff members annual appraisal (with the exception of the newly established borders service), which included a variety of objectives to achieve. For example service development and training. We were provided with the training records for all five services. Our assessment of viewing these records informed us that staff receive a good level of training. All staff complete an induction course which includes a variety of modules to cover, for example risk assessing, person centred awareness and adult support and protection. All staff have or were scheduled to receive shortly training in aggressive management and positive behaviours. This training had been specifically tailored to the type of support provided at Park and Cameron Cottages. More specialist training is also provided as and when required to meet the needs of service users. Such training included suicide intervention, benefits and epilepsy awareness. We spoke with a staff member who had recently joined the service to explore with her, her experience to date and what the induction covered. We found the induction process to be well managed, structured and included a period of shadowing more experienced support staff. Carr Gomm is a registered SVQ training centre and have two full time SVQ assessors in Carr Gomm - East & Midlothian, page 21 of 30

22 post. A number of staff were progressing well with training, relevant to their roles. We looked at the staff meeting records across all five services and the evidence told us that regular meetings are being held in a consistent approach, relevant to the operational needs of the individual services. All meetings were structured and actions were agreed. Agenda items typically included service user updates, policies and procedures and other service delivery matters. During our inspection the service provider was undertaking an employee satisfaction survey, with the intention to identify further ways of supporting the development of the staff and services. We looked at the findings across Midlothian and East Lothian, where the services operate from, with the exception of the Borders service. With a return rate of 26% questionnaires from those issued, 71% of staff were either satisfied or very satisfied with working for Carr Gomm. We were advised by the registered manager that an action plan would be produced to address any areas of improvement and development as has been the approach in previous years. We were also told that Carr Gomm hold a national staff award in recognition for their achievements at their annual general meeting, to which service users are also invited to attend. Areas for improvement With regards to the three support and supervision meetings per year, we identified gaps within the Cameron Cottage, Parks Cottage and the visiting support service in Midlothian. At the visiting support service located in East Lothian, we could not see any evidence of support and supervision meetings being held in the past 12 months. We are therefore making the recommendation for the service provider to deliver the structure of staff support and supervision in a consistent approach across all five services, in accordance to their relevant policy. Please see recommendation 1. Due to the concerns of staff conduct and levels of professionalism, we are making the recommendation that boundary training (professional boundaries between service user and support staff) is provided to all staff and included in future induction training for new staff. Please see recommendation 2. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 2 Recommendations 1. The service provider should deliver the structure of staff support and supervision in a consistent approach across all five services, in accordance to their relevant policy. Carr Gomm - East & Midlothian, page 22 of 30

23 National Care Standards, Housing Support, Standard 3 - Management and staffing arrangements. 2. The service provider should introduce professional boundary training for existing staff and to also include it within the induction training for new employees. National Care Standards, Housing Support, Standard 3 - Management and staffing arrangements. Carr Gomm - East & Midlothian, page 23 of 30

24 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 Statements 1.1 and 3.1 have been taken into account for this statement. Areas for improvement Statements 1.1 and 3.1 have been taken into account for this statement. Grade awarded for this statement: 5 - Very 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 Carr Gomm has a quality assurance policy in place, which details the tools and methods used to continuously assess and review the quality of the service provided. The approaches used include: * Service user satisfaction surveys. * Asking service users for their feedback of the staff that support them, as part of the employees annual appraisal. * Audits of medication records (where applicable). * Spot checks (undertaken locally). The majority of services had good systems in place for checking the work completed by the support staff. Other examples included checking support files to ensure they were kept up to date. Carr Gomm - East & Midlothian, page 24 of 30

25 Areas for improvement We identified some serious concerns with regards to the management oversight and direction at both of the supported accommodation services we inspected; Cameron and Park Cottages. At our last inspection of the service, team leader positions were in place, thus providing assistance to the management of the service in the absence of the manager. These positions have now been dissolved, resulting in no management or leadership on shift when the manager is absent, through either not on shift, or on annual leave or sick leave. We explored what systems were in place with regards to the management and leadership of the staff team in the absence of the manager, and evidence told us that other than staff being able to contact a senior manager (who has limited knowledge of the service users needs), it was left to the staff team to make the decision themselves. This was evidenced through our discussions with staff and minutes of staff meetings. Given the nature of the support needs of the vulnerable adults who use the service and previous adult protection issues, this lack of management, leadership and direction on shift gives us cause for concern. As detailed within statement 1.3 of this report, a number of staffing issues have arisen which has had a detrimental effect on some service users. There are also concerns about staff feeling comfortable in using the whistle blowing policy as we are aware of a number of issues which have gone unreported by staff. Having more effective management and leadership on all shifts would support the process of addressing the lack of management oversight and support the role of the manager who has a wide remit due to the managing of the two services. There are also a number of inexperienced staff who have recently joined the services and therefore could potentially make what they feel is the right decision without the correct knowledge, experience and support from management. The service provider must address this area of concern and ensure the support staff have clear direction and leadership at all times for the safety and wellbeing of service users. We are therefore making this a requirement. Please see requirement 1. During the course of our visit to Cameron House we were made aware of a potential health and safety issue with the environment of the service. We identified a security matter which could have left service users open to higher levels of vulnerability. We took appropriate steps at the time and gave guidance to the manager to address the concern. Whilst we believe this security issue has been resolved, it did highlight the lack of acknowledgement as to the seriousness of the issue by the service provider. When we inspected the quality assurance systems in place at the five services, we found that the services operated very differently and there was a lack of consistency in how quality assurance checks are undertaken. For example, although some services had medication audit checks and financial checks, we did not see any evidence of any Carr Gomm - East & Midlothian, page 25 of 30

26 quality assurance checks being undertaken at the visiting support service in East Lothian, although we were advised that spot checks were undertaken. Other forms of quality checks included that of support file audit checks, however this was not consistent across all services we inspected. We are therefore making the recommendation that the services develop their systems of recording such as quality assurance checks. Please see recommendation 1. Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 1 Requirements 1. The service provider must review the current management and leadership arrangements at each of the services to ensure effective management oversight is in place at all times. This is to comply with the Scottish Statutory Instruments (SSI) 2011 No 210, Welfare of users. Timescale: 28 days from receipt of this inspection report. Recommendations 1. The service provider should look to develop more quality assurance systems and create further consistency in their approach and implementation across the services. National Care Standards, Housing Support, Standard 3 - Management and staffing arrangements. Recommendation 0. National Care Standards - Care at Home Standard 4 Part 5(Management and Staffing) - Providers should ensure that there are appropriate quality assurance systems in place. Carr Gomm - East & Midlothian, page 26 of 30

27 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 Since our last inspection of the registered service, the number of operational services has increased with the addition of the service located in the Scottish Borders, which is set to become larger in size. We are therefore of the view that the service provider should review the current registration arrangements and work with the Care Inspectorate to ensure the registration of services is relevant to the size and capacity. Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in the Care Inspectorate re-grading a Quality Statement within the Quality of Management and Leadership Theme (or for childminders, Quality of Staffing Theme) as unsatisfactory (1). This will result in the Quality Theme being re-graded as unsatisfactory (1). Carr Gomm - East & Midlothian, page 27 of 30

28 5 Summary of grades Quality of Care and Support Good Statement 1 Statement Very Good 4 - Good Quality of Staffing Good Statement 1 Statement Very Good 4 - Good Quality of Management and Leadership Good Statement 1 Statement Very Good 3 - Adequate 6 Inspection and grading history Date Type Gradings 18 Dec 2012 Unannounced Care and support 4 - Good Staffing 4 - Good Management and Leadership 5 - Very Good 15 Sep 2011 Unannounced Care and support 5 - Very Good Staffing Not Assessed Management and Leadership 5 - Very Good 28 Sep 2010 Announced Care and support 5 - Very Good Staffing Not Assessed Management and Leadership 5 - Very Good 13 Oct 2009 Announced Care and support 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good 6 Feb 2009 Announced Care and support 5 - Very Good Staffing 5 - Very Good Carr Gomm - East & Midlothian, page 28 of 30

29 Management and Leadership 5 - Very Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Carr Gomm - East & Midlothian, page 29 of 30

30 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: Carr Gomm - East & Midlothian, page 30 of 30