The Courtyard Care Home Service Adults Hansel Alliance, Hansel Village Broad Meadows Symington Kilmarnock KA1 5PU

Transcription

1 The Courtyard Care Home Service Adults Hansel Alliance, Hansel Village Broad Meadows Symington Kilmarnock KA1 5PU Inspected by: Sean McGeechan Type of inspection: Unannounced Inspection completed on: 13 November 2012

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 11 4 Other information 25 5 Summary of grades 26 6 Inspection and grading history 26 Service provided by: Hansel Alliance Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Sean McGeechan Telephone enquiries@careinspectorate.com The Courtyard, page 2 of 28

3 Summary This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change after this inspection following other regulatory activity. For example, if we have to take enforcement action to make the service improve, or if we investigate and agree with a complaint someone makes about the service. We gave the service these grades Quality of Care and Support 5 Very Good Quality of Environment 5 Very Good Quality of Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well The service has continued to provide a very warm and welcoming environment, where service users feel supported. The staff team were open and friendly in their interactions with service users and this was evident during our visit. This was also supported by comments from service users and their relatives, who stated they were very happy with the support provided by the staff teams at The Courtyard and Meadow View. Meadow View was particularly good at delivering a very high standard of care and support to young adults with profound learning and physical disabilities. This purpose built house was designed to a very high specification in addressing the complex care and support needs of this client group. The staff team were equal to this high standard in their attitude and approach in delivering a very good level of care. What the service could do better The service continues to adapt in trying to involve service users and encourage carers in the evaluation of the quality of the service being delivered. What the service has done since the last inspection The service has continued to provide a consistently very good standard of care and support to adults with learning disabilities. They have promoted the participation of service users, carers and staff in the development of the service. The Courtyard, page 3 of 28

4 Conclusion Inspection report continued The Courtyard and Meadow View have continued to deliver a very good standard of care and support to adults with a wide range of learning and physical disabilities. Who did this inspection Sean McGeechan The Courtyard, page 4 of 28

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 The Care Inspectorate will award grades for services based on findings of inspections. Grades for this service may change after this inspection if we have to take enforcement action to make the service improve, or if we uphold or partially uphold a complaint that we investigate. The history of grades which services have been awarded is available on our website. You can find the most up-to date grades for this service by visiting our website, by calling us on or visiting one of our offices. Requirements and recommendations If we are concerned about some aspect of a service, or think it could do more to improve its service, 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 but where failure to do so will not directly result in enforcement. - 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 and Regulations and Orders made under the Act, or a condition of registration. Where there are breaches of Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Inspectorate." The Courtyard was registered in April 2011 to provide a residential based care service to a maximum of 15 adults with learning disabilities. The service is provided in accommodation built on the grounds of the Hansel Estate in Ayrshire, with the following agreed levels of occupancy as detailed in the registration certificate: Five service users will be accommodated at No 3 The Courtyard, Four service users will be accommodated at No 5 The Courtyard, Two service users will be accommodated at No 4 The Courtyard, *Four service users will be accommodated at *No 8 The Courtyard. *No 8 The Courtyard, also known as "Meadow View" is a detached house which has been specially designed and purpose built to accommodate four people with profound physical and learning disabilities. The Courtyard, page 5 of 28

6 Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade Quality of Environment - Grade Quality of Staffing - Grade Quality of Management and Leadership - Grade Inspection report continued 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. The Courtyard, page 6 of 28

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 wrote this report after an unannounced inspection carried out by care inspector Sean McGeechan on: Tuesday 6 December 2012 between 10:00 and 15:00. Tuesday 6 December 2012 between 18:00 and 21:00. We reviewed and inspected the following documentation and records: Certificate of Registration Insurance certificate Service user care and support plans Service user review schedules Service user participation strategy Minutes of service user meetings Newsletter developed by the service Staffing schedules Feedback systems Staff training records Minutes of staff meetings Staff supervision schedules Staff rotas Internal service questionnaires from relatives Care Inspectorate questionnaires Activity plans Meetings and planning agreements with service users Medication records Interaction between service users and staff Accident incident forms Risk assessments We spoke to the following individuals: Service users (8) Carers (4) Support Staff (5) The Courtyard, page 7 of 28

8 The manager and deputy manager The external line manager Grading the service against quality themes and statements We inspect and grade elements of care that we call 'quality themes'. For example, one of the quality themes we might look at is 'Quality of care and support'. Under each quality theme are 'quality statements' which describe what a service should be doing well for that theme. We grade how the service performs against the quality themes and statements. Details of what we found are in Section 3: The inspection Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at The Courtyard, page 8 of 28

9 The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self assessment document from the service manager. The service had identified what they thought they did well, and some areas for development. Taking the views of people using the care service into account We received 5 returned Care Inspectorate questionnaires. During the inspection visit we met several service users. Service users, who were able to communicate verbally, spoke very highly about the staff and the care and support provided. The service users were very happy living in the homes within The Courtyard. During our visit we witnessed other service users who relied on other means to communicate their feelings and emotions. We could tell they looked well cared for, smiled, laughed and were comfortable in the care of the various staff members. We saw some very positive interactions and connections being made between service users and staff. Taking carers' views into account We received 7 Care Inspectorate questionnaires. During the inspection visit we met with 3 relatives. Comments received from carers via questionnaires and interviews: "Staff show a caring and understanding nature." The Courtyard, page 9 of 28

10 "The standard of care is first class." "All staff appear friendly, knowledgeable and approachable." Inspection report continued The Courtyard, page 10 of 28

11 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 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 Service Strengths The service has continued to explore and implement methods for service users and carers to influence the quality of the care and support provided. We reached this decision after we had spoken with the manager, staff members, service users and relatives. We also reviewed a number of relevant documents. The grade we have awarded for this Quality Statement is. The service had recently given questionnaires to service users and carers. This allowed people to make comment and suggestions about improvements to the service or raise issues or concerns. During the inspection process we reviewed the returned questionnaires which indicated a very high degree of satisfaction with the quality of service provided. When issues were raised they were responded to by the management. This was evidenced in letters and other forms of communication. This level of involvement from service users and carers was welcomed and appreciated by everyone who participated. The on going open door policy and friendly approach by the management and staff helped to focus on a positive outcome for service users and carers. Carers informed us that if they had any concerns they felt welcome and able to contact the management or member of staff to raise their concern and this would be dealt with appropriately. The design of the questionnaires was based round the Quality Themes and The Courtyard, page 11 of 28

12 Statements which reflected an understanding of the importance of the National Care Standards in influencing the quality of a service. This helped service users and carers understand and appreciate the kind of areas being looked at when evaluating the quality of a service. The service had responded to some difficulties in getting carers to attend regular monthly meetings by re-scheduling these meetings twice yearly. This action increased the attendance. Feedback from carers indicated that this was more acceptable and better suited for them to attend less frequently. This level of flexible response by the service indicated that they valued the input from carers and wanted them to feel part of the service. The service had involved service users and staff in the "Heartfelt" training, called "Quality Counts". This helped to develop teams of quality checkers that encouraged them to engage in the monitoring of the quality of the service. Support staff assisted service users through this process, by helping them attend meetings and with guidance and assistance helped them to communicate their feelings. This was then collated in minutes using pictures and symbols to help everyone understand the process. Being able to influence and control the way the service responded in supporting them in meeting their needs increased their self esteem and confidence. This involvement helped the service users feel valued and gave them a sense of worth. The service provided at Meadowview, for four young adults with profound physical and learning disabilities, faced considerable challenges in meeting service user involvement standards. Yet staff managed to ensure that, no matter the level of disability, they were able to make sure service users were involved in every process of their care and support. This was achieved by staff having a keen sense of the mannerisms and responses of the service users. Staff also made sure that there was no talking over people and with constant vigilance, staff were conscious to ensure that, service users were made to feel part of any conversation and included in every interaction which, gave a sense of value and appreciation of the service users as individuals. Service user's reviews were conducted on a six monthly basis and they had the opportunity to invite who they wished to attend. This was evidenced in the documentation we inspected. The service had a very good complaints procedure in place called "Hansel Courtyard Are You Happy with the Help You Get?" This included user friendly pictorial symbols to assist people to complete. There was also clear evidence to support that carers had access to the complaints policy and procedures, this gave details of Care Inspectorate and local authority social work contact information. The Courtyard, page 12 of 28

13 Areas for improvement The service has developed a very good standard of achievement in the participation of service users and carers in an inclusive and meaningful way. There is continual review of how this can be improved on in delivering a quality service. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Inspection report continued Based on the evidence provided during this inspection, the grade awarded for this Quality Statement is. We reached this decision after we had spoken with manager, staff members, service users and relatives during the inspection visit. We also reviewed a number of relevant documents and records and observed practice. The service incorporated a daily diary of checks and audits which ensured good communication between the support staff and thus helped address issues as they arose. There was good clear evidence of documentation detailing who was responsible for undertaking specific tasks which ensured that tracking systems could identify any gaps in performance. This helped with supervision and supporting staff in their daily work performance. During the inspection visit we witnessed prompt action being taken to address some medical issue with a service user, which had occurred overnight. This was immediately actioned in the morning, with a phone call and subsequent visit to the local GP surgery for an appointment with the practice nurse later the same day. This type of response ensured that whenever any concerns were raised that staff were quick and attentive to the needs of the service users and able to access medical advice and support when required. This also gave reassurances to carers that their relatives' physical, medical and mental health needs were being addressed. Relatives we spoke to confirmed that this was of great comfort to them. They had every confidence in the support staff in attending to these matters. We reviewed the care plans and other documentation and found these to be of a very good standard. The information was gathered with a clear sense of involvement of the service users and written in a person centred way. This we found was also reflected in the support staff's knowledge of the service user's care and support needs. Staff knew the service user's well and appreciated them as individual people. This helped to create a very supportive and caring environment were people felt The Courtyard, page 13 of 28

14 comfortable and welcome. Care plans included considerable information about service user's medical and health related issues and this was regularly reviewed and updated. There was also evidence that the service had accessed community learning disability professionals and others for support and advice. The involvement of these associated professionals was evidenced and implemented within the care plan documentation. This gave a picture of considerable coordination and cooperation to ensure that service users had access to a variety of health related professionals to ensure that they received the optimum care available. Care plan documentation included very detailed descriptions of any important daily routines and simple daily living preferences which allowed anyone reading the file to have an overview and understanding of the main activities undertaken by service users. These were separated into morning, afternoon, evening and overnight sections with detailed descriptions of the care and support each person required. Medication administration systems were reviewed and found to be of a very good standard. The pharmacy supplier had conducted their own audits six monthly to ensure correct procedures were being followed. This indicated that the service had an efficient and well documented recording system in place. Each individual service user had their own medication recording folder which was kept in their bedroom. Each person's medications were stored in a lockable cabinet secured to the wall in their bedrooms. This meant each person had their own individual medicine supply stored in their own room, which was administered privately to them. This gave a sense of personal individual care and support being delivered. Medication sheets inspected showed that these were completed correctly by staff, who signed and dated them appropriately. They also included good explanations added for medications prescribed on an as required basis. This meant staff had a good appreciation of the importance of ensuring people were properly medicated to address any medical issues, for example epilepsy. Care plan records indicated that GP reviews had been conducted annually. Prior to these reviews taking place, staff would complete Treatment Plans documentation which gave the GP undertaking the review some background knowledge and understanding of any issues or concerns about service users medical needs. Appropriate Adults with Incapacity certificates that we checked were completed and up to date. This ensured that all medical procedures and interventions being undertaken were done so under full legal authority. The standard of service provided at Meadow View was particularly challenging for the staff in addressing the physical support needs of some very profoundly physically The Courtyard, page 14 of 28

15 disabled young people. The staff did extremely well in addressing some of the very complex physical requirements of service users who required high levels of care and support. This support was provided in a caring and compassionate way with attention to the person as an individual. The staff showed an acute awareness of the service user's care and support needs. Including their unique individual characters and personalities, which was reflected in the positive interactions we witnessed during the inspection visit. Due to the complex care requirements of these service users, any deterioration in their physical health often resulted in hospital admissions. To assist these admissions the service had produced a booklet called "My Hospital Information Booklet" which went with service users during such admissions. This gave detailed information about their care and support needs, on going medical conditions, likes and dislikes, medications, allergies etc. This helped to ensure smooth transitions during admissions and good information sharing between professional care teams. Areas for improvement The service should endeavour to maintain the very good standards they have demonstrated during this inspection with respect to addressing the physical health needs of the service users. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Inspection report continued The Courtyard, page 15 of 28

16 Quality Theme 2: Quality of Environment Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths Based on the evidence provided during this inspection, the grade awarded for this Quality Statement is. We reached this decision after we spoke with the manager, staff members, service users and relatives during the inspection visit. We also reviewed a number of relevant documents and records and observed practice. Please also refer to comments under Quality Statement 1.1 for further information to support the grade awarded. The Courtyard houses provided a very warm, friendly and homely environment for the services users. Who were able to decorate and furnish their own bedrooms to their individual taste and choice. Service users were always involved in discussions and decision making processes about all aspects of furnishings, décor and general issues to do with the houses they lived in. This would often involve compromising and seeking agreement with others in coming to decisions about matters to do with the homes. This helped service users learn about making decisions in life and working with other people and interacting with others. The service managed to provide good evidence to support that they involved the service users in all these decisions, with regular meetings, this also helped the service users feel this was their home and made them feel relaxed and comfortable. This was supported by service users comments, who stated they felt this was their home and they were happy living there. Meadow View was unique, in that, the design of the environment had to address the issues of meeting the needs of people with profound physical disabilities. This was achieved to a very high standard, with wide access corridors and doorways for wheelchairs, hard wood flooring to allow easier movement of wheelchairs and equipment, extra large bedrooms, specially adapted bathrooms and sensory room, tracking hoist system throughout the home and large dining kitchen area. The Courtyard, page 16 of 28

17 However despite these environmental necessities, staff still managed to ensure the individual characters and personalities of the service users was evident throughout the home. This was achieved by the inclusion of age appropriate furnishings and décor, personalised bedrooms and making the environment as homely and welcoming as possible. This gave service users a feeling that this was, their place. Areas for improvement The service should continue to evaluate the environment that people live in and their locations. To ensure that service users have as much involvement and influence in the decision making processes that affect the places were they live. This will ensure that people feel valued and they will be listened to, which helps to provide them with a sense of satisfaction. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths Based on the evidence provided during this inspection, the grade awarded for this Quality Statement is. We reached this decision after we had spoken with manager, staff members, service users and relatives during the inspection visit. We also reviewed a number of relevant documents and records and observed practice. During our inspection we checked that the staffing schedule, registration certificate and insurance certificate were all up to date and appropriately displayed within the service. Maintenance records were well kept up to date as was all the servicing record documentation. This ensured that equipment and other mechanical devices used were maintained to keep service users safe when being cared for. The service provided evidence to support that, in relation to the maintenance of equipment, a well ordered recording system was in place. Accident and incident forms were documented and well completed, with good details, descriptions and explanations. This included any remedial action taken to address any concerns raised as a result of an accident or incident. Moving and Handling equipment such as profile beds, hoists, baths and other items were clean, well maintained and evidence of regular servicing was checked and up to date. The Courtyard, page 17 of 28

18 The service had recently introduced new Health and Safety procedures in relation to Fire Safety awareness and this training programme was being rolled out within the organisation. Staff were in the process of undertaking this training, each member of staff signed to confirm when they had received this training. We inspected the fire evacuation documentation and this was completed to a good standard with clear information about the levels of support each person required in the event of fire evacuation. There was evidence to support that staff had undertaken fire drills exercises. These factors all helped to reduce risks and ensure that service users could be dealt with safely in the event of fire. There was a good laundry system, in particular dealing with delicates or other special items of clothing. There was also a good system for dealing with any soiled bedding or clothing. Infection control issues were recognised by the staff. They appeared to have a good knowledge of the potential hazards and able to implement systems to address and minimise the risks of infection through cross contamination. This ensured that service user's well being and safety issues were addressed and any potential risk to their health was minimised. Food in fridges was checked, signed and dated. Night shift checked all food stocks overnight and any out of date items are removed. Any foods placed in fridges are dated when opened. Staff had been given food hygiene awareness training and this helped them support the service user's nutritional needs and prepare meals safely. Areas for improvement For the service to continue to maintain the good standards evident within the environments of The Courtyard and Meadow View to ensure the services users are supported in a safe environment. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 The Courtyard, page 18 of 28

19 Quality Theme 3: Quality of Staffing Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths The grade achieved for this Quality Statement is 5 - Very good. We decided to award this grade after we reviewed how the service involved service users and carers in the participation process to continually improve the quality of the service. Please refer to Quality Statements 1.1 and 2.1 for further information to support the grade awarded. We observed some excellent engagement between staff and service users. There was clear respect and dignity shown during such interactions. Service users we spoke to confirmed this. They also stated that, if they had any concerns, they would be able to talk to and raise these issues with the manager or the support staff. The service demonstrated that they involved service users and carers in the reviews. Service users had the choice of selecting who they wished to attend. This gave service users an opportunity to make their own choices and use the reviews as a way of influencing their futures. This level of involvement meant that service users and carers felt able to participate in the development of the service. Which in turn, gave them a sense of ownership and that their opinions mattered. During our inspection we witnessed service users who expressed, in their own ways, a great deal of satisfaction with the standard of service and contentment with the accommodation provided. Some also commented on the quality of the staff. We also spoke to relatives who spoke very positively about the quality of the service and their levels of satisfaction with the standard of care and support delivered by the staff teams. Evidence from returned questionnaires and letters of thanks and comments during interviews with carers indicated a high level of satisfaction with performance of the staff team and the quality of these individuals. The Courtyard, page 19 of 28

20 Areas for improvement The service should continue to develop and encourage various methods of involvement and participation of service users and carers in how they can be part of the developments within the service. Grade awarded for this statement: 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 The grade achieved for this Quality Statement at the last inspection in December 2010 was. We found that the service has sustained this grade. They have continued to provide care and support in a professional and motivated manner. The grading has therefore remained 5 - Very good. The service conducted regular supervision sessions with staff and this was evidenced by completed supervision planners and by interviews with staff who confirmed that these sessions were a regular occurrence. This encouraged the development of a cohesive staff team, who worked well together to ensure a comprehensive consistent level of support was delivered to service users. Staff we interviewed spoke positively about working for the organisation, they told us this was a good place to work and that there was a positive atmosphere and good team spirit. New members of staff described a good induction process, were they had several initial full days training and then a period of shadowing time within the service. Both these systems helped to give people the knowledge base required, including the time working alongside more experienced staff to ensure that the new recruits felt comfortable and supported in their new job roles. There was evidence that on going specialist training was available to address some of the more complex care needs of service users. This training was sourced from recognised accredited providers from their various fields of expertise. This gave a good standard of training. Which ensured that staff were getting the most up to date knowledge and skills in addressing these issues. Some of the staff team within Meadow View had considerable experience of working with people with learning disabilities and complex physical disabilities. This quality of experienced staff helped to provide competent role models for new staff to learn The Courtyard, page 20 of 28

21 from. Staff interviewed during the inspection, were clear about their job roles and responsibilities. Importantly they expressed a willingness and appreciation that being flexible helped them work together as part of a team. They also spoke very positively about maintaining dignity and the quality of life for service users. We observed a good mix of experienced long term employees and new staff, working together as part of an effective team. Areas for improvement The service should continue to build and develop the good staff team they have in place. The service should look to the future developments within the speciality of learning disabilities services and ensure that they keep up to date with current best practices. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 The Courtyard, page 21 of 28

22 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths The grade achieved for this Quality Statement is 5 - Very good. We decided to award this grade after we reviewed how the service involved service users and carers in the participation process to continually improve the quality of the service. Please refer to Quality Statements 1.1, 2.1 and 3.1 for further information to support the grade awarded. The service demonstrated a welcoming approach and attitude with regards to the involvement of service users and carers in the improvement and development of the quality of the service provided. There was a on going dialogue of communication and willingness to listen to comments and suggestions about ways to change and improve the service. Minutes of meetings conducted by the service were viewed as part of the inspection. These showed the service actively engaging with relatives in discussions and responding to any feedback and issues raised during meetings. There were positive comments made by several relatives about the staff team, and satisfaction with the standard of care and support provided. Areas for improvement The service should continue with the good work that has been undertaken in relation to service user and carer involvement. Grade awarded for this statement: 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 The Courtyard, page 22 of 28

23 Service strengths The grade achieved fort his Quality Statement is 5 - Very good. We decided to award this grade after we reviewed the quality assurance systems and checks the service has in place. We found that the service undertook a range of audits under their quality assurance systems to assess and improve the quality of service. These included: * audits of questionnaires * feedback from minutes of meetings * direct observation and feedback of staff practice * audits of accident and incident reports * audits and reviews of care and support plans * audits of medication procedures, both internal and external * evaluation of comments and complaints * Performance appraisal for staff. * Feedback from other professionals * Feedback from service users and carers Inspection report continued The service has a Participation Strategy which is reviewed regularly to evaluate and improve outcomes for service users. Carers were consulted frequently and this was supported by feedback from carers through the service's own internal questionnaires. This helped to evaluate the level of satisfaction with the standard of care being delivered. This also assisted to give ideas and suggestions about any improvements that could be made to continue to develop and improve the quality of the service. The organisation had provided training opportunities for service users and staff, under the "Quality Counts" heading with the aim of: developing teams of "quality checkers" who would make sure good things happen across the organisation. Staff completed questionnaires to assist the organisation to look at the quality of the services they provided. This meant that the organisation valued the opinions of the service users and staff. Regular service user's meetings were held, and we found evidence from minutes to support that, any suggestions and comments were acted on as appropriate. The management team were aware of the need to ensure that good quality monitoring processes were employed. This allowed the manager to detect areas of concern at an early stage and plan any corrective action. The service collated evidence in files based on the National Care Standards as a framework. This included a variety of information and evidence to support quality assurance checks, including complaints procedures and a variety of other The Courtyard, page 23 of 28

24 documentation. This helped staff to ensure that they were aware of the National Care Standards and how they impacted on the quality of care and support they deliver. The administration systems we inspected were found to be very good. With a well ordered and clearly managed documentation system in place that complimented the management in the delivery of a high standard of care and support. These systems ensured that the staff team were providing care and support in a safe and secure environment with well maintained and regularly serviced equipment. There was evidence of regular audits and checks being undertaken to review the quality of the service. Medication audits were inspected and these were found to be satisfactory in addressing any issues raised. The pharmacy supplier conducted their own medication audits six monthly and these were again satisfactory. Areas for improvement To further enhance the Quality assurance systems currently in place, the service should consider developing some formal feedback mechanism to include professionals and other external agencies. This would give the service additional information and further evaluation of the service being provided. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Inspection report continued The Courtyard, page 24 of 28

25 4 Other information Complaints No complaints have been upheld, or partially upheld, since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). The Courtyard, page 25 of 28

26 5 Summary of grades Quality of Care and Support - Statement 1 Statement 3 Quality of Environment - Statement 1 Statement 2 Quality of Staffing - Statement 1 Statement 3 Quality of Management and Leadership - Statement 1 Statement 4 6 Inspection and grading history Date Type Gradings 17 Nov 2010 Unannounced Care and support Not Assessed Environment Staffing Not Assessed Management and Leadership Not Assessed 8 Mar 2010 Unannounced Care and support Environment Not Assessed Staffing Management and Leadership Not Assessed 3 May 2010 Announced Care and support 6 - Excellent Environment Staffing Not Assessed Management and Leadership Not Assessed The Courtyard, page 26 of 28

27 12 May 2009 Announced Care and support Environment Staffing Management and Leadership 18 Mar 2009 Unannounced Care and support Environment Not Assessed Staffing Not Assessed Management and Leadership 16 Sep 2008 Announced Care and support Environment Staffing Management and Leadership 4 - Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. The Courtyard, page 27 of 28

28 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: The Courtyard, page 28 of 28