Castle Rock Edinvar Sheltered Housing Support Service Housing Support Service 1 Hay Avenue Edinburgh EH16 4RW Telephone:

Transcription

1 Castle Rock Edinvar Sheltered Housing Support Service Housing Support Service 1 Hay Avenue Edinburgh EH16 4RW Telephone: Inspected by: Lorraine McIntyre Beth Lynagh Type of inspection: Announced (Short Notice) Inspection completed on: 20 March 2014

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 14 4 Other information 28 5 Summary of grades 29 6 Inspection and grading history 29 Service provided by: Castle Rock Edinvar Housing Association Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Lorraine McIntyre Telephone enquiries@careinspectorate.com Castle Rock Edinvar Sheltered Housing Support Service, 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 5 Very Good Quality of Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well Castle Rock Edinvar Sheltered Housing delivers support in 14 purpose-built and varying styles of sheltered housing complexes to vulnerable people who reside in the Edinburgh, Midlothian and East Lothian locality. The Sheltered Housing Officers provide daily contact with the people who use the service, which is delivered 365 days per year and supported by personal alarm technology to offer out of hours emergency contact. People we spoke to spoke highly of the service and quality of support provided by the staff. What the service could do better Information recorded in the support plan must include a more detailed approach to risk assessment to ensure that all risks are identified and service users are protected from potential risk and harm. Staff must receive appropriate training on risk assessments in order that they fully understand the information required and how to record and update this when necessary. What the service has done since the last inspection The service continues to take on board any requirements or recommendations made through inspection visits and works to address these.the environment in each complex continues to be refurbished and decorated by the Provider, where and when required with the consultation and involvement of tenants. Castle Rock Edinvar Sheltered Housing Support Service, page 3 of 30

4 Conclusion Inspection report continued We thought the service was providing a very good level of support to its tenants. The people we spoke to told us how happy and supported they felt by the service and the staff. We will be looking for the service to sustain its very good level of support ensuring it continues to encourage the participation of the people who use it. Who did this inspection Lorraine McIntyre Beth Lynagh Castle Rock Edinvar Sheltered Housing Support Service, page 4 of 30

5 1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Prior to 1 April 2011, this function was carried out by the Care Commission. Information in relation to all care services is available on our website at This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April Requirements and recommendations If we are concerned about some aspect of a service, or think it needs to do more to improve, we may make a recommendation or requirement. - A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service based on best practice or the National Care Standards. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reform (Scotland) Act 2010 ("the Act") and secondary legislation made under the Act, or a condition of registration. Where there are breaches of Regulations, Orders or conditions, a requirement may be made. Requirements are legally enforceable at the discretion of the Care Inspectorate. ABOUT THE SERVICE WE INSPECTED Castle Rock Edinvar is a charitable registered social landlord regulated by the Scottish Housing Regulator and the Care Commission. Castle Rock Edinvar Housing provides a housing support service to those living in sheltered housing in Edinburgh, Midlothian and East Lothian. Sheltered housing gives older people additional support and security without taking away their independence. Each development had: * A sheltered housing manager on-site Monday to Friday * Individual flats which are safer and easier to manage; additional security (door entry system, personal emergency alarm) * A communal lounge for social activities; * A shared Laundry Castle Rock Edinvar Sheltered Housing Support Service, page 5 of 30

6 * Guest bedrooms that family and friends can book when they come to stay, for a nominal charge. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 5 - Very Good Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 5 - Very 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. Castle Rock Edinvar Sheltered Housing Support Service, 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 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 compiled this report following a short notice announced inspection. The inspection was carried out by Inspectors Lorraine McIntyre and Beth Lynagh on 19 and 20 March Feedback was given to the Housing Support Manager on 20 March In this inspection we gathered information from various sources including; *personal support plans *six monthly review records *various methods of consultation including meetings, questionnaires and newsletters *evidence from the most recent self assessment *staff training/supervision *staff personnel files *quality assurance and audits We visited the following sheltered housing complexes and spoke to the following people; *Heinsberg House, Penicuik *Crystalmount, Dalkeith *Shore Road Edinburgh * Housing Support Manager * 3 Housing Support Officers * 22 service users Also as part of the inspection process we issued 200 Care Standard Questionnaires of which 116 were returned. 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 Castle Rock Edinvar Sheltered Housing Support Service, page 7 of 30

8 doing well for that theme. We grade how the service performs against the quality themes and statements. Details of what we found are in Section 3: The inspection Inspection report continued Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at Castle Rock Edinvar Sheltered Housing Support Service, page 8 of 30

9 What the service has done to meet any requirements we made at our last inspection The requirement The service provider must ensure that reviews of housing and support plans are undertaken on a six monthly basis or less if required. This is to comply with the Scottish Statutory Instruments (SSI) 2011 No 210, Personal Plans (5.2b,c,d). Timescale: 8 weeks on receipt of this inspection report. What the service did to meet the requirement From the evidence we were presented with we concluded that the service were reviewing support plans at least once in every six month period to comply with current legislation requirements. The requirement is: Met - Within Timescales The requirement The service provider must ensure risk assessments are undertaken for all residents and reviewed on a six monthly basis or less, as and when required. This is to comply with the Scottish Statutory Instruments (SSI) 2011 No 210, Personal Plans (5.2b, c & d). Timescale: 8 weeks on receipt of this inspection report. What the service did to meet the requirement Risk assessments were in place in the support plans and were being reviewed regularly, therefore, this requirement has been met. However the information recorded needs to be improved and staff require further training and support in order to complete these appropriately. Please refer to Quality Theme 1 and 3 for further information. The requirement is: Met - Within Timescales The requirement The service provider must ensure, before employing staff, that it carries out the appropriate disclosure check for the work to be performed; in particular, a PVG check for staff who will perform any work in the care service which is regulated work under the PVG Scheme. Also, that it carries out and records appropriate risk assessments to ensure that safeguards are in place in any exceptional circumstances when it is Castle Rock Edinvar Sheltered Housing Support Service, page 9 of 30

10 necessary to commence induction of any new staff before the appropriate check has been made. This is to comply with the Scottish Statutory Instruments (SSI) 2011 No 210, Welfare of users regulation 4(1)(a), Fitness of employees (9.1) and Protection of Vulnerable group listings, regulation 13(1.). Timescale: On receipt of this inspection report. What the service did to meet the requirement From the evidence we were presented with we concluded that all staff received PVG checks and this was recorded in their personnel files. At the previous inspection the service had employed a staff member and commenced their induction period prior to the PVG check being completed. The newly appointed staff member was shadowing a more experienced Sheltered Housing Officer for a short period of induction. As this practice had not been repeated since the last inspection we were unable to determine if any new systems to ensure the safeguarding of tenants had been implemented if a PVG check had not been received. A new recruitment policy had been introduced and a recently employed staff member had a record of a satisfactory PVG check in place. This requirement has been met however please refer to Quality Theme 3 for further information on this requirement. The requirement is: Met - Within Timescales Inspection report continued What the service has done to meet any recommendations we made at our last inspection The following recommendations were made at the previous inspection with progress as follows; 1. The service provider should review the material provided to tenants and carers regarding the complaints procedures. National Care Standards, Housing Support, Standard 8 - Expressing your views. The complaints procedure was available in the welcome brochure and on the notice boards in the complexes we visited. The tenants we spoke to said they were familiar with the procedure but would always approach the sheltered housing officer first and were confident it would be resolved at this stage. This recommendation has been MET. 2. The service provider should ensure that all tenants have a service housing and support plan in place when beginning to use the service. Castle Rock Edinvar Sheltered Housing Support Service, page 10 of 30

11 National Care Standards, Housing support, Standard 4 - Housing support planning. The support plan contained two sections, the first section was completed when the tenant commenced the service, the second section was the completed following a period of assessment and first review. This recommendation has been MET. 3. The service provider should review the systems in place to allow the tenants, support staff and the Care Inspectorate to access these documents. National Care Standards, Housing support, Standard 3 - Management and staffing arrangements. Staff we spoke to told us they were aware of how to access policies and procedures online. The customer handbook provided tenants with information on how to access policies and procedures relevent to their needs, for example the complaints procedure and annual performance review. This recommendation has been MET. 4.The service provider should review their safer recruitment policy to reflect the PVG Scheme operated in Scotland to provide further clarity in relation to safer recruitment practices. National Care Standards, Housing Support, Standard 3 - Management and staffing arrangements. Since the previous inspection the Provider had introduced a more detailed and up to date policy for recruitment which refered to the Scottish Executives 'Safer Recruitment through Better Recruitment procedure. This recommendation has been MET. 5. The service provider should ensure staff are appropriately trained in relation to the completion of risk assessments for the individuals the service provides care and support to. National Care Standards, Housing Support, Standard 3 - Management and staffing arrangements. The health and safety department had provided a training session to staff on risk assessments. This had also been discussed at staff meetings with the health and safety department. Castle Rock Edinvar Sheltered Housing Support Service, page 11 of 30

12 This recommendation has been MET, however, please refer to Quality Theme 3 for further areas for development. 6. The service provider should implement a quality assurance policy, detailing the aims and objectives, along with the tools and methods in place to assess the quality of the service provided. National Care Standards, Housing support, Standard 3 - Management and Staffing arrangements. Since the previous inspection the provider had introduced a quality assurance policy which included staff recruitment and development. This recommendation has been 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. 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 issued 200 Care Standard Questionnaires of which 116 were returned. This included 92 from tenants, 15 from relatives/carers and 7 did not indicate who had completed these. Two of the questionnaires returned were for home support services and not sheltered housing. The results and comments were as follows; 92% said they knew they had a support plan Castle Rock Edinvar Sheltered Housing Support Service, page 12 of 30

13 95% said the service checked with them regularly to ensure it was meeting their needs 97% said they were confident staff had the necessary skills to support them, treated them with respect and were overall happy with the quality of the care and support provided. 89% said they were familiar with the complaints procedure and 83% knew how to complain to the Care Inspectorate. " when my husband died last year, the manager/warden could not have been more helpful reminding me about contacting pensions, council, etc., he is an excellent hard-working manager" " fantastic housing manager, don't know what we would do without him, goes beyond the call of duty " " having been here only two years I was disappointed that I was not informed of building work, ie., new cottages to be built on the garden grounds, as the gardens were a deciding point for me coming here. It is distressing for all especially the more elderly whose only way of getting out is to walk round the beautiful award-winning gardens which is being taken away for building and car parking" " very happy here, everyone is extremely kind and helpful " " although the manager is always busy she always makes time for everyone and goes out of her way to help in any way she can " " I came here nearly two years ago, it seemed to be an ideal place where I could enjoy the garden. Had I known the garden was to be built on and beautiful trees cut down I would not have come, why spoil something so beautiful ". Taking carers' views into account Please refer to views of people using the service for further information. Castle Rock Edinvar Sheltered Housing Support Service, page 13 of 30

14 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths We found that the service was performing at a very good level when we assessed this Quality Statement. At this inspection we focused on personal support plans, reviews, methods of consultation and spoke to tenants and staff. In the foyer of the sheltered housing complexes and common rooms there was a range of posters, brochures and leaflets. These included a copy of the most recent Care Inspectorate report, complaints procedure, Castle Rock Edinvar newsletter and pictures of tenants enjoying various outings and activities. There was also information on the managers working hours and service user comment forms, encouraging people to comment on the standard of service. Each new tenant received a recently upgraded welcome brochure. This was a very well written and informative brochure informing prospective tenants what to expect from the service and the limitations of support. This also contained a copy of the complaints procedure with information and contact details for the Care Inspectorate. The support plans provided evidence of consultation with tenants as well as a signed tenancy agreement and consultation in the six monthly review process. The people we spoke to told us they knew they had a support plan which was reviewed regularly. Consultation and discussions with the tenants and sheltered housing officers took place daily on an informal basis and any matters were dealt with as they arose; for example, repairs and maintenance issues. People we spoke to had high regard for the staff and said they were aware of the complaints procedure and how to complain to the service and Care Inspectorate. The tenants we spoke to said if they had any concerns/complaints they would rather Castle Rock Edinvar Sheltered Housing Support Service, page 14 of 30

15 speak to the Sheltered Housing Managers and were confident that any issues raised would achieve a positive outcome. The results from the Care Standard Questionnaires indicated that 89% of tenants were aware of the services complaints procedure and 83% of people were aware of how to complain to the Care Inspectorate. Some of the people we spoke to told us they participated in the sheltered and amenity forum meetings which took place three times a year. This provided an opportunity for tenant representatives to meet and discuss any issues from their own complex, hear about what was happening in other complexes and receive any relevant updated information. about the overall service. Pre-forum meetings were held which encouraged all tenants to meet and discuss any issues they wanted raised on their behalf at these meetings. Minutes and action plans were available in each complex as well as in the newsletters, this ensured everyone was kept fully informed of future developments and changes within the service. Some of the complexes had social committees who organised fund-raising events and met regularly to organise events and outings. People told us they had enjoyed outings to local areas for lunch, had organised a knitting group, poetry reading and gardening groups and said. " have plenty going on, we have gardening competitions and activity evenings, we like to be active and busy ". "we have keep fit on a Monday and poetry on a Tuesday, a monthly Scotts night and plenty of Bingo". There were regular church services, a mobile library and bus organised to take people to the local supermarket for their weekly shopping. Castle Rock Edinvar's newsletter kept people informed of any corporate changes while some complexes produced their own newsletters to update tenants on more local issues and events. One of the tenants in Crystalmount ran a weekly computer class for anyone wishing to learn or update their skills. This group worked in partnership with a local volunteer group who provided laptops and I Pads for use to anyone who wanted to be involved. One tenant told us "my son lives abroad and since coming to the computer class I learned how to send s and can now keep in more regular contact with my son". The Provider was proactive in continuing to refurbish and upgrade the complexes with kitchen and bathroom upgrades taking place. Any work undertaken was done with the consultation of the tenants, with comments as follows; " just got a new floor, sink and toilet was given a choice of colours to choose from" " my refurbishment is not complete yet, it's very nice and was given the choice of coloured flooring". Castle Rock Edinvar Sheltered Housing Support Service, page 15 of 30

16 Areas for improvement The six monthly review records should be developed to include space for recording the full details of any areas discussed at these meetings. The information available did not always reflect the full review or discussions which had taken place, for example, "no change or "none" was regularly recorded. The review records did not always reflect the titles of the people who attended therefore it was not always clear if it was a family member, staff or someone from an outside agency. (see recommendation 1). Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. Reviews should provide the opportunity to discuss and agree any changes to the support plan based on the tenants changing needs and views. This document should be signed by all persons' present at the meeting, with their title or role recorded. Any changes to tenants needs should be recorded in an updated support plan. This is in order to comply with; National Care Standards, Housing Support Services, Standard 4: Housing Support Planning. Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Inspection report continued We found the service was performing at a very good level in the areas covered by this statement. We looked at personal support plans and spoke to tenants who said they felt very well supported, safe and secure within their homes. We looked at the support plans which consisted of two parts. The first part of the plan was an assessment and was developed when a new tenant commenced the service. It provided a section to record personal details and those of next of kin or advocate; medical history, medication and safety matters. The second part of the plan was completed within eight weeks and contained more specific information relevant to current healthcare needs and risk assessments following the initial assessment. Each personal plan contained a signed service user agreement and had dates of six monthly reviews and who would be involved in these. There was information recorded from other agencies who provided any additional support required and this information was used in the review process to discuss people's changing needs. Castle Rock Edinvar Sheltered Housing Support Service, page 16 of 30

17 Tenants safety and well-being checks were monitored and recorded up to three times a day by the Sheltered Housing Manager. Each person's house/flat was fitted with a sensor beam which monitored people's movement and allowed the SHM to check if the person was up and mobile. In addition to this, some people wore personal alarm pendants providing added security. This provided instant access to a local support base who then deployed support workers to assist tenants who required help or had fallen. Any alarm activations were recorded by Elcas (East Lothian Community Alarm System) and details provided to the manager identifying the reasons for the call, actions taken and people involved. These alarm pendants were checked monthly to ensure they remained in full working order. There were details available in the complexes of individual tenants mobility and cognitive limitations providing the emergency services with quick access to important information needed in the event of an emergency or evacuation. There was a health and safety committee in place who met regularly. We saw the minutes of previous meetings with action plans attached from these. Representatives from the health and safety committee conducted regular audits of each complex and provided an audit summary report. This had resulted in an accident working group who monitored accidents and put measures in place to prevent further recurrence. People were encouraged and supported to maintain links with the local community and were able to choose if they wished to participate in the social life of the complex through activities such as knitting, arts and crafts, gardening, bingo or outings. Some of the comments we received were as follows; "we are very fortunate to have the support of our manager who is happy and willing to support us in many ways from technical issues to tea in the lounge, also helps people who feel isolated and lonely which is an amazing boost to moral and most gratefully appreciated by the tenants". "I feel safe here and know that my needs will be taken care of as they change over the years ahead". "my aunt feels very happy with the care she has, the officer is very caring and helpful. My aunt loves living here, the lounge is a great meeting place for a chat and cup of tea and she feels very safe and secure". The previous inspection identified that staff were working a dual shift in two of the complexes. This involved staff working in one service in the morning and covering another one in the afternoon. We found that there were still occasions where this was happening in order to cover sickness or annual leave. Since the previous inspection the provider had recruited more staff and had sought the views of the tenants in the complexes involved, people who were asked said that they understood Castle Rock Edinvar Sheltered Housing Support Service, page 17 of 30

18 the reasons why this was sometimes necessary. A recent survey asked if tenants wanted staff to be on call out with office hours and weekends. Tenants had said this was not necessary and were happy with the service as it was. We will continue to monitor this at future inspections to ensure that these dual shifts are only used to cover sickness and annual leave and are not common practice. The Sheltered Housing Officers had access to a range of policies and procedures on the Group intranet and the staff we spoke to told us they knew how to access these if required. Castle Rock Edinvar Housing Association produced a customer handbook for all its tenants. There was a section in the handbook which explained how people could get information and become involved in how their housing service is managed. It referred people to the Provider's website and explained that information was available on tenancy terms, policies on housing, repairs and participation, participation strategy and action plan, complaints procedure and annual performance review. Areas for improvement Inspection report continued Although there was good information in the support plans there was no information on how the service managed and evaluated any risks identified. For example, it was unclear what measures had been put in place to reduce the risk for people with mobility or visual impairments. This important information should be included in the fire evacuation register as it was unclear the level of support needed by tenants in the event of an emergency situation. For example, if a wheelchair was required or if the person was registered blind or deaf (see recommendation 1). There should be a note of essential information at the front of the support plans explaining the relationship of the next of kin to the tenant. There should also be a record of any important legal requirements, such as Power of Attorney, as well as any recorded wishes relating to anticipatory care planning or Do Not Resuscitate Orders (see recommendation 2). We found that each complex was using the same documentation to record information in the support plans and review documentation. However, we found that the standard and amount of information recorded varied in each complex with some sheltered housing managers recording more detailed information than others. The provider should look at ways of monitoring this to ensure that all information recorded is consistent throughout each of the complexes. (see recommendation 3). As mentioned at the previous inspection we found that the provider was still not notifying the Care Inspectorate of notifiable incidents, for example death or incidents involving the police (see requirement 1). We discussed this with staff and the Housing Support Manager and directed them to the notification guidance on the Care Inspectorate website. Castle Rock Edinvar Sheltered Housing Support Service, page 18 of 30

19 Policies and procedures were available on the Group intranet, however, these did not provide a date of issue or review date in order to demonstrate they were up to date and in line with current legislation and best practice guidelines. Grade awarded for this statement: 5 - Very Good Number of requirements: 1 Number of recommendations: 3 Requirements 1. The Provider must notify the Care Inspectorate of the death of any service user who has died while the care service was being provided to the service user and the circumstances of death. This must also include any serious injury, theft, allegation of misconduct or outbreak of infectious disease. This is in order to comply with The Regulation of Care(Requirements as to Care Services)(Scotland)Regulations 2002.Regulation 21 Notification of death,illness and other events. Timescale; to commence immediately upon receipt of this report. Recommendations Inspection report continued 1. The service should develop the support plan further to include information in relation to identified risks and actions to be taken by staff to minimise these risks. These risk assessments should be evaluated regularly or when needs change and should be used to update the support plans. This important information should be included in the fire evacuation register as it was unclear the level of support needed by tenants in the event of an emergency situation, for example, if a wheelchair was required or if the person was registered blind or deaf. This is in order to comply with; National Care Standards, Housing Support Services, Standard 4: Housing Support Planning. 2. The service should ensure that essential information is recorded at the front of the support plans and includes who has the legal powers to make decisions on the tenants behalf, for example Power of Attorney or Guardianship powers. This is in order to comply with; National Care Standards, Housing Support Services, Standard 4: Housing Support Planning. 3. The Provider should introduce a method of ensuring that all completed documentation provides a consistent level of information from each of the complexes. Information in the support plans and six monthly reviews should provide the same standard of necessary information completed by the staff members. This may involve providing staff with further training and competency assessments. This is in order to comply with; Castle Rock Edinvar Sheltered Housing Support Service, page 19 of 30

20 National Care Standards, Housing Support Services, Standard 3: Management and Staffing Arrangements and Standard 4: Housing Support Planning. Castle Rock Edinvar Sheltered Housing Support Service, page 20 of 30

21 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 From the evidence we were presented with we concluded that the service was performing at a very good level in areas covered by this statement. The service had recruited additional staff since the last inspection, however, there was a low staff turnover which limited opportunities for tenants to be involved in the recruitment and induction process. People we spoke to spoke highly of the staff and management and commented how supportive and satisfied they were with the staff and level of support provided. Tenants said they were comfortable and happy to speak to staff informally on a dayto-day basis, they felt listened to, well-informed and knew how to complain. They said they were confident that any issues raised were dealt with effectively by the sheltered housing manager. The recruitment policy encouraged tenant involvement in the recruitment of new staff, either in groups, individually or by producing a set of agreed questions to be used at interview. The people we spoke to said they were happy with the level of involvement they presently had within the service. Some of the comments received were as follows; " We have an excellent manager/warden to whom we can turn to at any time" " I have lived here for just under two years and have found it a very comfortable, well run and happy environment. The manager is most efficient and really goes out the way to create a friendly atmosphere among the tenants" " I have never been in a situation where my request/complaint has not been addressed within a reasonable timescale, I am very happy with my managers handling of any issues I have raised ". Castle Rock Edinvar Sheltered Housing Support Service, page 21 of 30

22 Areas for improvement Further work could be done by the provider by looking at ways to involve tenants in the future recruitment of staff. For example, feedback from tenants and carers on staff performance at induction could be used when assessing the quality of service delivered by staff, through, for example, staff supervision and appraisal. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 2 We are confident that our staff have been recruited, and inducted, in a safe and robust manner to protect service users and staff. Service strengths From the evidence we were presented with we concluded that the service was performing at a very good level in areas covered by this statement. We looked at this statement in order to assess the progress made since the previous inspection in relation to the necessary recording of Protection of Vulnerable Group (PVG) checks. The recruitment policy had recently been renewed and explained that successful candidates would be appointed subject to the necessary checks of PVG, references, medical and qualification check. New staff had a disclosure information record sheet in their files which contained all the necessary information and demonstrated that the staff member had been employed following receipt of this information. As there had only been one new staff member appointed since the previous inspection, we had no new documentation or standard of recording to review for this quality statement. New employees received a comprehensive induction which covered a range of subjects including health and safety, policies and procedures and the use of various internal communication channels. They were also assigned to a 'Buddy' who mentored and supported them throughout their induction/probationary period. New staff were issued with a first step employee handbook. This provided good information on the induction process, structure and values of the organisation a summary of policies and procedures. Areas for improvement Inspection report continued At the previous inspection it was highlighted to the manager that newly appointed staff must have the necessary checks in place prior to commencing employment. We discussed this again with the housing support manager who informed us that new staff had previously been employed and had commenced a shadowing/induction period prior to the receipt of a Protection of Vulnerable Group check being received. Castle Rock Edinvar Sheltered Housing Support Service, page 22 of 30

23 This involved the new staff member having an introduction to the environment, meeting the tenants and becoming familiar with the documentation under the constant supervision of an experienced, existing member of staff. The service should ensure that the appropriate risk assessments are in place in order to safeguard tenants should this practice be repeated again in the future. We will continue to monitor this at future inspections as there was no evidence to demonstrate if this was happening due to the lack of newly appointed staff. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths Inspection report continued We found that the service's performance was very good in the areas covered by this statement. We found staff to be friendly, motivated and helpful with good interaction and knowledge of the people they were supporting. Each Sheltered Housing Manager had access to a range of information, including policies and procedures on the Group intranet which provided instant access to staff for easy reference. There were also copies of the Scottish Social Service codes of practice and the National Care Standards. Regular meetings were taking place between the manager and the sheltered housing staff. These meetings discussed training needs, health and safety issues and updates on any complaints received. These meetings had been used to inform staff on the correct way of completing and updating the risk assessment document. The training department organised staff training and this was accessible to employees on the intranet. Staff we spoke to told us they received a range of training opportunities and had attended courses in; dementia, financial abuse, adult support and protection and first aid, this included updates from the Health and safety department which covered a session on risk assessments. The housing support manager was in the process of developing a training matrix in order to identify when the sheltered housing staff required training updates. Staff have been supported to attain the SVQ level 3 in Housing Support and were in the process of registering with the Scottish Social Service Council. Castle Rock Edinvar Sheltered Housing Support Service, page 23 of 30

24 Staff told us they had regular supervision with their line manager who was very supportive and approachable. Appraisals were carried out annually with information on the previous years sessions discussed to ensure that any issues raised were successfully met. We received 17 completed Care Standard Questionnaires from staff prior to this inspection, 8 staff indicated they were not familiar with policies on restraint, recruitment and outings and 2 were unsure of the whistleblowing policy and participation strategy. Comments received were as follows; "I enjoy working for Castle Rock Edinvar and feel fully supported in the role I do from my line manager ". "All Sheltered Housing Managers meet with senior managers 4 times a year but many of us would like to be able to meet in smaller groups to share experience and knowledge, think this could be very beneficial". "Sheltered Housing Managers provide housing support only, therefore, we do not have policies in place for restraint, recruitment and outings". Areas for improvement Staff had received a training session from the Health and Safety department on risk assessments with further information and guidance on how to complete these being discussed at staff meetings. However, from the standard of documentation we sampled in relation to risk assessments we concluded that staff required further training and support in the completion and update of these documents, for example one person had a risk assessment document completed that failed to identify the actual risk but indicated it had been reviewed and was up to date. (see recommendation 1). Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The Provider should ensure that all staff receive appropriate training in the completion and update of the risk assessment documents contained within the support plans. The standard of documentation and staff competency in the completion of this should be reviewed and recorded through supervision or auditing to demonstrate their accuracy. This is in order to comply with National Care Standards, Housing Support, Standard 3: Management and Staffing. Castle Rock Edinvar Sheltered Housing Support Service, page 24 of 30

25 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths We found that the service was performing at a very good level in areas covered by this statement. The tenants we spoke to told us they had daily contact with staff and felt they were kept well-informed of what was happening within the service. They said they had no hesitation in raising any concerns with the staff and were confident any issues raised would be dealt with efficiently. Tenants had regular reviews of their support plans and had the opportunity through tenant meetings to raise any concerns. The roles and responsibilities of the Housing Support Managers had been discussed at a recent tenant forum meeting and this provided another opportunity for people to comment on the standard of management and support. Areas for improvement The provider should look at ways of using the information/ feedback and incorporate this into staff supervision and appraisal. 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 We found that the service was performing at a very good level in areas covered by this statement. Castle Rock Edinvar Sheltered Housing Support Service, page 25 of 30

26 Since the previous inspection an improved quality assurance policy had been introduced which monitored the internal and external quality standards within Castle Rock Edinvar Housing Association. As part of the quality assurance system the manager and staff performed regular health and safety walkrounds of each complex. This ensured the environment was safe and well maintained, any areas of concern were highlighted in an action plan with outcomes recorded. These checks also included the monitoring of specific maintenance tests to ensure they were up to date, for example, gas maintenance, water hygiene and fire maintenance. Additional audits were conducted by the health and safety compliance officer and any areas of concern were recorded and discussed at health and safety meetings attended by staff. Accidents/incidents and complaints were recorded in each service and audited by the Housing Support Manager. Details of accidents and incidents were recorded and reviewed by the Health and Safety Department and any areas of concern were highlighted and discussed with the Manager. Each Sheltered Housing Manager had an open door policy and spoke to service users on a daily basis. This helped ensure that any concerns were dealt with promptly before becoming an issue. The people we spoke to told us that they felt confident that any issues raised were dealt with appropriately by the staff who made themselves accessible during office hours. Areas for improvement We were told that the Sheltered Housing Officers regularly completed unannounced spot checks on services as part of the quality assurance process. However these checks were not recorded. As discussed at the previous inspection the service would benefit from recording these to evidence quality assurance practices. Although there had been no serious complaints logged, the Sheltered Housing Officers were dealing with informal issues and complaints on a regular basis. We discussed the importance of recording any issues with details of the outcomes achieved. regular audits of the support plans were taking place however, there was no evidence recorded of the audits, areas for improvement and actions/outcomes following these (see recommendation 1). Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 Inspection report continued Castle Rock Edinvar Sheltered Housing Support Service, page 26 of 30

27 Recommendations Inspection report continued 1. The service should ensure that any audits are recorded in a suitable format and contain details of the audit, actions required, person responsible and timescale for completion. This is in order to comply with National Care Standards Housing Support Services Management and Staffing Arrangements. Castle Rock Edinvar Sheltered Housing Support Service, page 27 of 30

28 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 No 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 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). Castle Rock Edinvar Sheltered Housing Support Service, page 28 of 30

29 5 Summary of grades Quality of Care and Support Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Staffing Very Good Statement 1 Statement 2 Statement Very Good 5 - Very Good 5 - Very Good Quality of Management and Leadership Very Good Statement 1 Statement Very Good 5 - Very Good 6 Inspection and grading history Date Type Gradings 13 Mar 2013 Unannounced Care and support 4 - Good Staffing 4 - Good Management and Leadership 5 - Very Good 29 Jun 2010 Announced Care and support 5 - Very Good Staffing 5 - Very Good 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. Castle Rock Edinvar Sheltered Housing Support Service, 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: Castle Rock Edinvar Sheltered Housing Support Service, page 30 of 30