Hansel Day Services Support Service Without Care at Home Hansel Alliance, Hansel Village Broad Meadows Symington Kilmarnock KA1 5PU Telephone: 01563

Transcription

1 Hansel Day Services Support Service Without Care at Home Hansel Alliance, Hansel Village Broad Meadows Symington Kilmarnock KA1 5PU Telephone: Inspected by: Sean McGeechan Michael Thomson Type of inspection: Unannounced Inspection completed on: 4 September 2012

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 10 4 Other information 21 5 Summary of grades 22 6 Inspection and grading history 22 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 Hansel Day Services, page 2 of 24

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 4 Good Quality of Staffing 4 Good Quality of Management and Leadership 5 Very Good What the service does well The staff and management works well at creating a welcoming and friendly atmosphere within the day care service environment at Hansel. Service users and carers have commented very positively and provided written statements in returned Care Inspectorate questionnaires about how they value and appreciate the quality of the service provided. The day services have managed to create a valued outreach resource for people living in the community. There is a keen focus by the service to develop and enhance community based experiences and help people to access community based resources. The service is constantly investigating and developing new opportunities for activities and partnerships with other agencies and organisations to enhance the positive image of people with learning disabilities in the wider community. What the service could do better The service has experienced some difficulty in their attempts at getting relatives to attend meetings to discuss and assist with the future developments within the service. The service is awaiting the completion of a new build project on the grounds of the Hansel estate which has been described as a Therapeutic Building. Hansel Day Services, page 3 of 24

4 Mandatory training requirements for staff need to be updated. Inspection report continued Testing of all portable electrical equipment needs to be undertaken including the implementation of an annual schedule of testing. What the service has done since the last inspection The service has continued to provide and develop an important and welcomed support to people with learning disabilities in their day care service and the outreach community supports. The service has taken over new service provision for younger adults going through transitional stages. The success of taking over this contract provision has been reflective of the good work of the service. Conclusion The day service at Hansel provides an environment that is enjoyable and welcoming for people to attend. The day services provides a flexible outreach service to people living in the community and encourages people to get out and about and access local facilities. Service users spoke of being happy going to the day service and liked the activities they did during their visits as well as the outings and trips they went on. Who did this inspection Sean McGeechan Michael Thomson Hansel Day Services, page 4 of 24

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 Hansel Day Service is based within a cabin style building within the grounds of the Hansel estate. There are several rooms used for various arts, crafts and group or individual activities. There is a self contained kitchen which can be used for training in independent living skills. There is strong focus on accessing the local community for outings, trips and activities that encourage social and personal skills development. Currently there are around 135 people accessing the various levels of support under the umbrella of the day services. About 20 of these individuals presently live within the residential provision on the Hansel estate, the rest are people who live either at home with carers or in various different community based supported living services. The service was registered on 1 April 2011 to provide a maximum of 140 adults with Hansel Day Services, page 5 of 24

6 learning difficulties of whom 35 may be supported at any one time within the service's base at Broad Meadows, Symington. The service may be provided between 7.00 and each day Monday to Sunday. In the absence of the manager, who will be supernumerary, a responsible person must be designated to be in charge of the care service. 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 Environment - Grade 4 - Good Quality of Staffing - Grade 4 - Good Quality of Management and Leadership - Grade 5 - Very Good 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. Hansel Day Services, page 6 of 24

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 sent out 20 questionnaires and received 11 returned completed. 5 were returned from service users. 6 were returned from carers relatives. We undertook this inspection between and on Tuesday 4 September Sean McGeechan and Michael Thomson, care inspectors conducted this inspection. We reviewed the following documentation: Participation strategy Day service newsletter Staff training records Care Inspectorate questionnaires Service internal questionnaires Staff supervision schedule Complaints records Activity plans in-house and community based Personal plan agreements with service users Review meetings Observations of the premises Resources and interaction between service users and staff Personal Plan review documentation Accident incident forms Minutes of staff meetings, referred to by service as (POD meetings) Fire safety documentation Risk assessments Staff rotas communications from manager to external agencies We spoke to the following people: Service users (5) Manager Support staff (5) Hansel Day Services, page 7 of 24

8 Relatives (3) We conducted a tour of the premises checking the various rooms within the building which service users accessed for crafts, activities and group work or individual sessions. We noted how each room was decorated with the various work and presentations completed by service users, the most recent addition being a large Olympic poster and collage display. Service users we spoke to were very proud of their work and keen receive recognition and appreciation for this. Which we could tell enhanced their self esteem and confidence about their abilities in a positive way. 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 Hansel Day Services, page 8 of 24

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 Comments from returned questionnaires "I am very happy with Day Services; I really like everyone at Day Services. It is good fun." Taking carers' views into account Comments from returned questionnaires "We have used Hansel Day Services and have been delighted with the support received. Our only reservation has sometimes been that management do not inform us when support workers change at short notice. This is very important." "I have good support from all of my son's care workers." "The only complaint is that I do not know a lot of what my son is doing. So a diary might be a good idea. I have suggested that but it has not happened yet." "Hansel provide a very good service to my daughter who looks forward to meeting her support worker and always returns happy and relaxed, we couldn't ask for more." Hansel Day Services, page 9 of 24

10 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 The service had continued to involve service users and carers meaningfully in developing the quality of care and support therefore the grade for this Quality Statement has been maintained at 5 - very good. We came to this decision after talking to service users, carers, the manager and the staff and reviewing various documents within the service. The service demonstrated a very good level of understanding and appreciation for the need to involve service users and carers in the participation process within the service. Feedback received from completed Care Inspectorate questionnaires indicated service users and carers were happy with the level of service being provided and how they were involved with the service. The service works well with service users and carers to ensure their needs and wishes are met. One carer wrote "Hansel provides a very good service to my daughter who looks forward to meeting her support worker and always returns happy and relaxed, we couldn't ask for more." The service gave out their own internal questionnaires to service users and carers. The feedback from these was positive and reflected a level of satisfaction and appreciation of the value of the service provided. People we spoke to were very complimentary about the service and the staff. This reflected how the service supported people to engage in meaningful activities within the day service at Hansel but also enjoy an active programme of community based pursuits. This helped to keep people motivated and giving them purposeful activities to enjoy which also further enhanced their self esteem and confidence. Information and feedback from these questionnaires was shared with staff at their Hansel Day Services, page 10 of 24

11 staff team meetings, which the service refer to as 'POD' meetings. Copies of the minutes of these meetings was given to each member of staff which ensured good communication and sharing of information, so that everyone was kept up to date with issues within the service. This also helped people share ideas and suggestions and staff reported they felt part of a team. Carers whom we spoke to during our inspection said that they were very happy with the service, they felt informed and involved with the manager and staff at the day service. The carers confirmed that they were regularly kept up to date and immediately informed of any issues of concerns, as well as positive developments too. One carer wrote, "I have good support from all of my son's care workers." Staff had completed daily progress notes for each person, which provides a valuable record of activities that people have been involved in. This also helped to inform carers and relatives of progress and inform future planned programmes of activities. Areas for improvement The service had already recognised and documented previous difficulties in getting relatives to attend various organised meetings and events to discuss future developments. The service continues to investigate ways of getting people involved in the participation and future developments within the day services. The service rely on phone calls as the main source of contact with relatives and this should be continued to ensure regular updates and feedback. There were some comments about lapses in this communication. One carer commented; "We have used Hansel Day Services and have been delighted with the support received. Our only reservation has sometimes been that management do not inform us when support workers change at short notice. This is very important." The service should be particularly aware of the need for continuity and consistency when providing community based supports to people and the need to keep carers notified immediately of any changes to support staff. 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 The service had continued to involve service users and carers meaningfully in developing the quality of care and support therefore the grade for this Quality Hansel Day Services, page 11 of 24

12 Statement has been maintained at 5 - very good. Inspection report continued The service had produced some very good documentation which ensured that all relevant health and care information was completed and available. Personal plans were completed with good individual detail and all the necessary information and important contacts were included and easily accessible. There was clear detailed evidence of very good pre-assessment information gained from service users, carers and other professionals, this helped to refine and review the care and support plans. Personal support plans were completed in a person centred approach which ensured the individual was at the centre and focus of any programme of support being considered. Staff signed each personal support plan file after they had read them, which ensured that all staff had a good understanding and general knowledge of all the service users and their needs. This ensured a good standard of consistency and approach by all staff when supporting service users. We found that care and support was being delivered in a person centred way. We observed the staff to be sensitive and caring when interacting with service users. When talking with staff we found them to be very knowledgeable and appreciative of the service user's individuals support needs. We found that staff were clear about their roles and responsibilities in ensuring that appropriate support was delivered to service users.. There was an awareness and consideration of the individuals needs when planning activities and how best to meet their needs in a supportive manner. Care staff were familiar with the keyworker system, this identified an individual person who was responsible for developing the agreed support package from initial assessment stage to the implementation and review of personal support plans. The personal plans also evidenced some good examples of involvement of other professionals when required. These included speech and language therapy, psychology, Royal National Institute for the Blind and a variety of other professional support services which constituted a multi-disciplinary team approach. This contact ensured that the full array of a persons physical, social, and psychological needs were being considered and that staff within the service were aware and observant towards the different needs of the service users. The service had compiled a folder of photographs to help staff with proper moving and handling procedures. This included detailed photographs of the correct use of the Hansel Day Services, page 12 of 24

13 various positional equipment required by some service users with profound physical disabilities. This ensured all staff could easily see the correct positions and appropriate ways to use this equipment which kept service users with physical disabilities safe and supported. Staff complete progress notes on a daily basis detailing the activities and progress people were making. This helped to ensure service users involvement was continually being assessed and reviewed. We found evidence of service users being supported in complaint handling situations, by helping them to make complaints about incidents of poor service they had experienced in community settings. This helped to develop service users self esteem and confidence about standing up for their rights and feeling valued as a person. Areas for improvement The service should develop the way they complete their records relating to the activities undertaken and the aims and outcomes. When completing these it would be helpful to focus more on the descriptions and define the detail of the aims and outcomes rather than simply writing the record of the activity. For example: Swimming could also include encouraging physical exercise and healthy living. i.e. base this on the outcomes of the activity. Documentation around reviews needs to be progressed more formally. Some reviews had been undertaken but no review documentation had yet been forwarded. The service needs to follow up and ensure appropriate documentation is sent after meetings and reviews have been conducted. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Hansel Day Services, page 13 of 24

14 Quality Theme 2: Quality of Environment 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 environment within the service. Service strengths The grade we awarded for this statement was 5 - very good. As identified in Quality Statement 1.1 the service used a range of methods to involve and encourage feedback from service users and their families. This information was used by the service to review and influence changes within the service and how they delivered the care and support to the service users. Areas for improvement The service has plans to develop and move to a new purpose built premises within the grounds of the Hansel estate. This is being described as a Therapeutic Building and the service have been actively seeking the views and suggestions of service users and carers in this process. Grade awarded for this statement: 5 - Very Good 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 The grade we awarded for this Quality Statement is 4 - Good. 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. In discussions with the manager there was an understanding of matching staff to service users and ensure that the staff had the necessary skills and experience to provide the level to support and assistance required. When talking with staff they confirmed that the manager was approachable and open to them if they had any issues or concerns to address. During a tour of the premises we noted that the service users were able to display examples of their completed crafts and art. They also used current topics, for example the 2012 Olympics, to generate themes and suggestions for activities to engage Hansel Day Services, page 14 of 24

15 people. We noted how each room was decorated with the various work and presentations completed by service users, which they were very proud of. This helped service users to see an end product to all their hard work and feel motivated to continue with new projects. We reviewed accident and incident forms and found they 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. We found evidence of the service completing good risk assessments relating to service users support needs. The service gave consideration to the variety of complex and at times challenging support needs of service user when allocating staff support. This ensured that all staff working with people in the community had the skills knowledge and experience to appropriately support service users when out in the community. General maintenance issues were addressed appropriately and the manager stated that any concerns or faults requiring attended to were dealt with promptly. We viewed a repair log that detailed any remedial work carried out. Areas for improvement The service should review all portable equipment testing procedures to ensure that all items are properly tested. This is should then be conducted on an annual basis. To ensure that the potential risk of injury or fire from faulty portable electrical equipment is reduced. The Health and Safety Executive advices that all portable electrical equipment should be subject to "regular testing" which it then states is generally interpreted as an "annual test". Heath and Safety Executive - Maintaining Portable and Transportable Electrical Equipment - HSG 107, (See Recommendation 1 of Quality Statement 2.2.) The service has recognised the need to move to new premises and is in the process of building a new designed for purpose building within the grounds of the Hansel estate. This is being described as a Therapeutic Building, which the day service will be managed from. A final opening date has still to be set. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. The service should review all portable equipment testing procedures to ensure that all items are properly tested and this is then conducted on an annual basis as is Hansel Day Services, page 15 of 24

16 best practice guidelines. This is to comply with the National Care Standards Your environment. Hansel Day Services, page 16 of 24

17 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 The grade we have awarded for this Quality Statement is 5 - very good. We reached this decision after we reviewed relevant documentation spoke to service users and carers about how the service involved them to engage in the allocation and discussion about staff. Please refer to comments written under Quality Statements 1.1 and 2.1 for further detailed information regarding the strengths of this quality statement. Areas for improvement The service have been investigating more formals ways of involving service users and carers in the recruitment process. 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 The grade we have awarded for this statement is 4 - good. New staff we spoke to confirmed they had been given good induction to the service and felt valued by this experience. They were very positively about the induction training given at the start of their employment. This supported staff in their new jobs and gave them an important sense of worth and value to the organisation and their work. This also helped to be better prepared for when working with adults with learning disabilities. However, in reviewing other staffs training records it was noted that some of the mandatory training requirements were out of date and thus required immediate refresher training. This issue was discussed and management agreed that they would Hansel Day Services, page 17 of 24

18 address this matter urgently. During staff meetings or 'POD' meetings as they are referred to the manager included discussions about the National Care Standards. This was to encourage staff to reflect on how standards and legislation impacts on their daily work. This helped staff appreciate and be considerate of the external guidance and policies that influenced their work practices. Areas for improvement When we viewed and inspected the mandatory training requirements some were found them to be out of date and several staff required refresher training updates. The service need to address this issue and implement a programme of scheduled training for all staff whose mandatory training requirements are out of date. We were unable to check staff recruitment records as these are held within the head office administration department. (Please refer to requirement 1 in Quality Statement 3.3 Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. 1.The provider must ensure that all staff are appropriately trained to meet residents' needs at all times, and any mandatory training requirements are updated. In order to achieve this, the provider shall: a. Review training gaps within the service. b. Put in place a staff training programme based on this review. National Care Standard Management and staffing arrangements Hansel Day Services, page 18 of 24

19 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 The grade we have awarded for this Quality Statement is 5 - very good We reached this decision after we reviewed relevant documentation spoke to service users and carers about how the service involved them to engage in the allocation and discussion about staff. Please refer to comments written under Quality Statements 1.1, 2.1 and 3.1 for further detailed information regarding the strengths of this quality statement. The service had previously been part of the Investors in People award certification, which has recently ceased. The service has been investigating other external evaluation and accreditation. One example is that the Hansel organisation has been listed on the Sunday Times Best Companies to work for (not for profit sector). Areas for improvement We noted that some people were not aware of the complaints procedures or how to complain to the Care Inspectorate if the wished. The service needs to ensure that all service users, carers, relatives and staff are fully aware and have access to appropriate complaints processes. The service should ensure that this in place and relevant records kept as appropriate. The service should continue to engage with professionals and other agencies who can provide external review of their quality assurance systems. This can be helpful to the overall development and future progression of the service. 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 Hansel Day Services, page 19 of 24

20 Service strengths The grade we have awarded for this Quality Statement is 5 - very good. We found a variety of quality assurance systems in place to monitor, assess and review the quality of the service being delivered. These included: * audits of questionnaires * feedback from minutes of staff meetings * direct observation and feedback of staff practice * evaluation of comments and complaints * Performance appraisal and supervision for staff. * Feedback from service users and carers * Monitoring of accident and incident documentation The management team were aware of the need to ensure that good quality monitoring processes were implemented. This allows managers to detect areas of poor practice at an early stage and plan any corrective action. The manager had conducted internal questionnaires for service users and carers and collated the returned information. This helped to evaluate the level of satisfaction with the standard of service being delivered. This helped to generate suggestions about any improvements that could be made that would help continue to develop and improve the quality of the day services. Areas for improvement The service should continue to review all aspects their quality assurance systems to ensure that they are continually reflecting and assessing the quality of the service they are providing. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Hansel Day Services, page 20 of 24

21 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). Hansel Day Services, page 21 of 24

22 5 Summary of grades Quality of Care and Support Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Environment Good Statement 1 Statement Very Good 4 - Good Quality of Staffing Good Statement 1 Statement Very Good 4 - Good Quality of Management and Leadership Very Good Statement 1 Statement Very Good 5 - Very Good 6 Inspection and grading history Date Type Gradings 14 Oct 2010 Announced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed 1 Mar 2010 Announced Care and support 5 - Very Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed 12 Aug 2008 Announced Care and support 5 - Very Good Environment 5 - Very Good Staffing 4 - Good Management and Leadership 4 - Good Hansel Day Services, page 22 of 24

23 All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Hansel Day Services, page 23 of 24

24 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: Hansel Day Services, page 24 of 24