Edinburgh Secure Services Secure Accommodation Service 39 Howdenhall Road Edinburgh EH16 6PG Telephone:

Transcription

1 Edinburgh Secure Services Secure Accommodation Service 39 Howdenhall Road Edinburgh EH16 6PG Telephone: Inspected by: Duncan Craig Suzanne Beard Type of inspection: Unannounced Inspection completed on: 24 November 2011

2 Contents Page No Summary 3 1 About the service we inspected 6 2 How we inspected this service 7 3 The inspection 12 4 Other information 25 5 Summary of grades 26 6 Inspection and grading history 26 Service provided by: City of Edinburgh Council Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Duncan Craig Telephone enquiries@scswis.com Edinburgh Secure Services, 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 N/A Quality of Management and Leadership 3 Adequate What the service does well We found that the service provided very good care and support to young people who, for a variety of reasons, required to spend time within a secure environment. The service focused on, and maintained, a very good balance between its statutory security obligations and the provision of supportive, child centred care. Young people's health was managed and promoted very well. We found that staff at all levels were highly skilled in establishing and developing close and constructive professional relationships with young people. We found, as at previous inspections, that the care and education components of the service worked very well together. We found that the service had embraced the ethos of service user and parent/carer participation and had established this within decision making and planning. The participation policy and procedure, "Count Me In", was firmly embedded within all aspects of life within the service. The service was very well managed and staffed. Young people told us that they felt safe within the service. The service and the provider continued to incrementally improve the living environment. What the service could do better We found that, overall, the service had effective recording and monitoring arrangements in place. However, the service requires to improve key aspects of recording and monitor these areas accordingly. Edinburgh Secure Services, page 3 of 28

4 The service requires to ensure that the Care Inspectorate is notified of incidents and occurrences as per "Guidance on notification reporting - All registered care services " published by SCSWIS. The service provider should continue to ensure that a good quality living environment for young people is maintained. What the service has done since the last inspection The service had recently undergone a change of Principal. The previous incumbent had moved on to a promoted post and the Depute was in an "Acting up" position. We found, and were told, that this transition was being well managed. We found that the service continued to develop and operate its excellent participation strategy, "Count Me In". Young people spoken with were confident and knowledgeable regarding raising issues through different routes, including directly approaching the Principal and other managers. We found that the participation strategy, "Count Me In", was firmly embedded within the culture and practice of the service. Young people's health continued to be managed very effectively. The service was commencing Tier 2 "Health Promoting" status having previously secured Tier 1. The provider and the service continued to strive to improve the physical environment within both Secure Houses. The Principal stated that communication and understanding with the building provider/contractor continued to improve. Maintenance of bedrooms was no longer tied to a set programme of redecoration and had been decorated prior to inspection. The service had worked hard to ensure that staff were registered with the Sottish Social Services Council (SSSC). For those without appropriate qualifications, training plans were in place and being implemented. The service was introducing a new change management tool for work with staff. This approach, known as "ADKAR", allowed for the identification of change desired and/or needed and provided a stepped and considered approach for change based upon "Awareness, Desire, Knowledge, Ability and Reinforcement". Conclusion The evidence at this inspection confirmed that Edinburgh Secure Service provided very good care and support to young people who were experiencing considerable difficulties in their lives. There was also evidence that the parents/carers of young people were being supported and involved. The balance between security and care was very good and enabled young people to feel safe and valued. Managers and staff were committed to a shared vision and ethos based upon child centred care. The service's participation strategy, "Count Me In", had become part of the culture and "language" of the service and was understood and valued by young people, their parents/carers and external stakeholders. Young people's health and wellbeing had a very high profile within the culture of the service and was managed very effectively. Edinburgh Secure Services, page 4 of 28

5 Edinburgh Secure Services is very well managed and staffed. The service is committed to providing high quality intervention, care and support to young people and their parents/carers. This is reflected by the views of young people, their families and other stakeholders. The secure component of the service is very effectively complemented by the integrated Close Support and Throughcare/Aftercare provision Who did this inspection Duncan Craig Suzanne Beard Edinburgh Secure Services, page 5 of 28

6 1 About the service we inspected Edinburgh Secure Services is made up of two separately registered types of service; a Secure Accommodation service and a care home service termed "Close Support". The care home service includes a "Throughcare and Aftercare" component. The operation of both services is fully integrated. The inspection of both services is carried out simultaneously but reported on separately. Edinburgh Secure Services consists of Braid Secure House, based at Howdenhall Centre and providing six placements, and Guthrie Secure House, based at St. Katharine's Centre, also providing six placements. St. Katharine's and Howdenhall sites are close to local amenities and convenient for local transport. The stated aims of the service is are "to provide for young people, whose behaviours pose a serious risk to themselves or others, a safe, secure, supportive and stimulating environment in which they will achieve their full potential, develop respect for themselves and for others and be assisted in gaining an understanding of the attitude, skills and knowledge that will enable them to return safely to their communities". As both Houses provide secure education on the premises, National Care Standards (NCS) for "School Care Accommodation Services" are employed in addition to NCS for "Care Homes for Children and Young People. The educational provision is regulated by Her Majesty's Inspectors of Education (HMIe) and was reported on, following inspection, in September The Secure Accommodation service is approved by the Secretary of State in line with The Secure Accommodation (Scotland) Act 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 5 - Very Good Quality of Staffing - N/A Quality of Management and Leadership - Grade 3 - Adequate 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. Edinburgh Secure Services, 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 This inspection took place, in conjunction with the inspection of the service's Close Support and Throughcare/Aftercare provision, on the 10, 11 and 24 November, The inspection was carried out by Inspectors Duncan Craig and Suzanne Beard of the Care Inspectorate. The inspection was unannounced. We enjoyed a meal with young people in both Braid and Guthrie Houses, and spent time speaking with individual and sub-groups of young people regarding their experience of the service. Seven young people completed and returned Care Standards Satisfaction questionnaires to us. We met with the Principal and the managers of Braid and Guthrie Houses. A number of staff members spoke with us regarding their experience of, and contribution to, the service. Following inspection, the views of four social workers with experience of the service were gathered. We also spoke with a placing social worker during inspection. Policies, procedures and records were examined. Staff practice, and interaction between young people and staff, was observed throughout the inspection. 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 Edinburgh Secure Services, page 7 of 28

8 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 Edinburgh Secure Services, page 8 of 28

9 What the service has done to meet any requirements we made at our last inspection The requirement A Requirement resulted from the joint HMIe/SCSWIS Inspection Report of September "In addition to the continued provision of the City of Edinburgh Children's Rights Service: The provider must put in place a strategy to ensure that young people also have the option to access external advocacy services. This is to comply with Scottish Statutory Instrument 2011/210. Regulation 4(1)(a). Timescale for implementation: within three months of receipt of the final report. What the service did to meet the requirement The timescale for meeting this requirement was December The service forwarded to us and our HMIe colleagues copies of a very detailed and easily read "Advocacy Strategy". This policy document detailed young people's advocacy rights and how to access different services and agencies. The policy also told young people how, and by whom, they would be supported in contacting these bodies. An "Advocacy Flyer" was also available and would be given to and discussed with each young person upon admission. The policy was being introduced on 19 December The service had responded very positively to this requirement and it is deemed as "Met". The requirement is: Met What the service has done to meet any recommendations we made at our last inspection One Recommendation was made following the then regulator's (Scottish Commission for the Regulation of Care) unannounced inspection of February 2011: "The service provider should continue to ensure that a good quality living environment, incorporating choices for young people, is maintained. The young people's request for a bath to be fitted should continue to be progressed by the Principal through the Residential Review Group. Whilst welcoming the recent investment in Guthrie Unit, the building is "tired" and needs further attention to both young people's living areas and office areas. NCS 5 School Care Accommodation Services - Comfort, Safety and Security. NCS 5 Care Homes for Children and Young People - Your Environment. Outcome: We saw that improvements continued to be made throughout the service, Edinburgh Secure Services, page 9 of 28

10 most notably a bathroom within Guthrie House had been fitted. in place.this recommendation has been met but remains relevant. See recommendations within Quality Statement 2.1. of this report regarding continued improvements. The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The service had completed a self assessment as requested by the Care Inspectorate. From the information given it was clear that they had taken time to describe their work in relation to the Quality Themes and Statements. They referred to their policies and procedures and gave examples of their work to evidence how they met the Quality Themes and Statements. They highlighted aspects of their service that they thought they did well and described how they would improve other aspects in future. Taking the views of people using the care service into account We spoke with the majority of young people living in Braid and Guthrie Houses. This was either in a sub group setting or individually. We enjoyed a meal and discussion with young people in both Houses. Six young people completed and returned Satisfaction Questionnaires. Views regarding the service were predominately very positive, with the positive features of staff involvement, safety, food and care planning being highlighted. In response to the statement "Staff treat me fairly and with respect", four young people "Agreed" and two young people "Strongly Agreed". These views were echoed by the young people we spoke with during inspection. In response to the statement "Overall, I am happy with the quality of care I get here", three young people "Agreed" and three young people "Strongly Agreed". Again, these views were reflected by the young people we spoke with. Young people told us that the felt safe and listened to. They told us that they felt able to raise issues or concerns with staff and managers and that they always got a response. Young people related incidents where specific members of staff had helped them and/or advised them appropriately. Edinburgh Secure Services, page 10 of 28

11 They felt their involvement in the service had been helpful to them and their parents/ carers. They described how their health was managed and how they were supported by staff to access treatment or health advice. Comments included: "I think this is a good place and the best place I have been" "It's OK and I get on with most kids and staff" "Being here has helped me to make sure my next placement works" "I get on well with all the staff - there's always someone there" Two young people felt they should have more access to the inter-net and two young people stated that they were not introduced properly to new staff members. Taking carers' views into account We were not able to speak with parents/carers as part of this inspection. However, we spoke with one social worker at inspection and four social workers following inspection. They spoke highly of the service their respective young people received and highlighted very effective communication with staff as a key factor. The care planning process was described as "very effective and inclusive". They told us about significant positive change in young peoples lives. One worker highlighted the effective balance of "listening to young people" while maintaining "appropriate boundaries". Another worker commented very positively upon the "What Am I?" tools and how they had enabled them and their young person to measure improvements in self esteem. Edinburgh Secure Services, page 11 of 28

12 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 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 young people and their families had excellent opportunities to become involved in evaluating and developing the quality of individual and group care and support provided by the service. The service continued to operate its "Count Me In" participation strategy and there was excellent evidence that this had become "bedded in" to individual care planning and general decision making processes. Prior to, or upon, beginning their placement within the service, young people and their parents/carers were provided with an information pack that detailed life within the service and gave details of important contacts, including the Children's Rights Officer and the Care Inspectorate. This pack explained the importance of participation and outlined the "Count Me In" strategy. Young people and other stakeholders told us that they were familiar with the strategy and knew how to access it. Each meeting within the service, be it young person or staff focused, included "Count Me In" on the agenda. Young people themselves, or staff as advocates, could raise issues at the request of individual or sub - groups of young people. This was reflected within meeting minutes and "Action Points" were identified. The Principal and House Managers were informed of all issues raised through "Count Me In" and we found evidence of their positive intervention. We found examples where "daily living" expectations had changed as a result of this process. For example, the times young people had to turn off their TV's in their rooms. The service had designed specific "Count Me In" suggestion/observation/complaint cards for young people, parents/carers and visitors to the service. Additionally, we saw excellent evidence of the service regularly conducting exit interviews/ questionnaires focused upon young people, their parents/carers and their attached social work or health professional. Periodically, the service sent out questionnaires to all stakeholders to assess satisfaction with the service. Responses were collated, and comments Edinburgh Secure Services, page 12 of 28

13 considered in development plans as well as for immediate action through key workers and/or managers. At recent inspections parents/carers told us that they felt fully involved in decision making regarding their child. They said communication between them and the service was "excellent" and that they had developed very good relationships with their child's Key Worker and other staff. The service had held two "Parent/Carer" meetings, the most recent being within a Bar - B - Q setting and it was planned to continue with this group. A model was in place for young people's meetings that included "rotating" chair and minuting arrangements. The success of these was reflective of the service user group at any given time. However, we saw that meetings had been more regular since the previous inspection. Young people said these meetings worked well and this was reflected in minutes. Staff members were committed to facilitating opportunities for young people to raise issues through both formal and less formal routes. Young people confirmed to us that they felt able to raise issues with staff and managers and that they felt their views were listened to. All the young people spoken with knew the Principal and stated that they felt able to raise issues directly with him if necessary. However, they told the officer that issues tended to be resolved through discussion with key workers or other staff members. One of the managers lead regular group work with young people regarding "Group Living" where the views of young people were explored with a view to promoting positive group living and inter-personal "problem" resolution. Excellent care planning and key working systems remained in place that provided consistent opportunities, from admission onward, for young people, and their family/ carers, to reflect upon, review and plan their care and support. There were many examples of effective parent/carer contributions within key time records and family support records within care plan files. We found that the service continued to enjoy very effective relationships with external agencies and services. We found that the Children's Rights Officer and the LAAC Nurses maintained very good relationships with the service. We observed very good quality discussion between staff and young people throughout the inspection. It was evident that staff had built very strong and supportive relationships with young people, through which young people were empowered to make suggestions and discuss issues about the quality of care and support they received. Young people and their parents/carers were fully involved in the Looked After and Accommodated Children (LAAC) review and planning process. Formal Complaints and Suggestion arrangements were in place including a "Suggestion" box on each House. The Children's Rights Officer (CRO) was a member of the "Complaints Information Group". The CRO had a very high profile within the service and was held in high regard by young people and staff. Edinburgh Secure Services, page 13 of 28

14 The "relaxed and positive relationships" between staff and young people noted at previous inspections remained evident. Areas for improvement The service should continue to operate and develop the excellent "Count Me In " strategy. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Statement 2 We enable service users to make individual choices and ensure that every service user can be supported to achieve their potential. Service strengths Inspection report continued Young people's opportunities to exercise "day to day" choices need to be viewed within the context of a secure environment. We found that care planning and review arrangements were very good with young people fully involved in both internal and LAAC review processes. The very good Key Worker system included the production of jointly negotiated "Weekly Plan" that detailed each young persons activities and commitments for the week ahead. We saw evidence of Key Workers advocating for young people and ensuring that their views were heard. The "Count Me In" system, as detailed in Quality Statement 1, Quality Theme 1, ensured that young people could make their wishes and opinions known. We saw that a very good ongoing assessment tool, "Who Am I?" was being used to assist young people identify their positive characteristics to build upon and areas for self development. We found that young people had very good access to information, through literature and group events, with which to inform decision making regarding aspects of their lives. For example, regarding health, alcohol, offending and sexuality. A Mobile Library visited the service and each House had a "Reading Champion" to encourage reading generally. Young people were involved in menu planning and their was an appropriate choice of food at meal times. Young people we spoke with were satisfied with the catering arrangements and told us about aspects of self catering and acquiring catering skills. We saw that young people had access to a broad range of activities both within the centre and, where applicable, within the community. We saw very good art and craft work, heard about trips to local attractions and saw young people and staff engage in activities within the living areas. Young people had access to the educational resources of the service including the gym and information technology. We found that the service had developed a direct link with The Duke of Edinburgh award scheme. A member of staff had been trained in assisting young people in Edinburgh Secure Services, page 14 of 28

15 taking part in activities with this scheme. Young people across the service had also been involved in a range of community groups such as Seven Doors (an arts organisation promoting young people's involvement and interest in the arts) and Young Enterprise (an organisation promoting global awareness, raising funds for charities and disaster appeals). During inspection, some young people were working with "Young Enterprise" to raise funds. They spoke enthusiastically to us about this project. Young people were able to add personal items to their bedrooms and choose their own toiletries, either by directly purchasing them or by ordering on line. We observed very good deescalation techniques being employed in response to minor incidents of challenging behaviour. Options and consequences were discussed with young people, enabling them to manage their own behaviour through positive choice. Areas for improvement The service should continue to promote positive choices within all aspects of young people's lives. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Edinburgh Secure Services, page 15 of 28

16 Quality Theme 2: Quality of Environment 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 environment within the service. Service strengths As recorded within Quality Theme 1, "Quality of Care and Support", Statement 1, the service had a range of systems in place through which young people's views and the views of relevant others were sought. Very positive relationships between young people and staff, coupled with clear and mutually accepted expectations regarding behaviour within a group living context, promoted a calm, safe and inclusive living environment. This enabled young people to experience an ordered and constructive daily life experience. Young people told us that they felt safe, valued and listened to and spoke positively of their day- to- day living experience. We saw evidence in Care Planning meetings, LAAC reviews, keytime records, resident's meeting minutes and from discussion with young people that they had opportunities to comment on the quality of the environment. Young people were encouraged, as far as was possible, to personalise their rooms with pictures, posters and other personal items. Young people's art and craft work was displayed in the communal areas. This gave a positive impression of life within each unit. Where possible, young people were involved in choosing furniture and fittings. This was evident within Guthrie House where a significant sum had been spent to improve unit decor. Additionally, a bathroom had been created in response to the wishes of young people. The work of the Handy Person had played a significant role in improving the living environment for young people, especially in carrying out a programme of bedroom decoration. Staff and Managers demonstrated a system for noting and recording repairs and other work which needed to be done to the fabric of the building and to fitments. Managers told us that the accommodation provider in relation to Braid House was "much more responsive" to the needs of the service and that communication with the provider was effective and regular. Both Houses presented as bright and welcoming and were clean and tidy. Areas for improvement As regards Braid House, the service provider should continue to negotiate with the accommodation provider to ensure that maintenance, repair, re-refurbishment and decoration arrangements meet the needs of the young people living within the Edinburgh Secure Services, page 16 of 28

17 service. Whilst the improvements within Guthrie House are welcomed, continuous improvement should remain on the agenda. The House looks "tired" compared to Braid. At inspection we noted an odour within Guthrie. The service was trying to identify the source of this. Staff areas within Guthrie House were observed to be in need of upgrade and, within the staff duty room, file storage needed upgrading to ensure reasonable access and secure storage. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 2 Recommendations Inspection report continued 1. The service provider should continue to ensure that maintenance, repair, rerefurbishment and decoration arrangements meet the needs of the young people living within the service. NCS 5 School Care Accommodation Services - Comfort, Safety and Security NCS 4 School Care Accommodation Services - Privacy and Dignity NCS 5 Care Homes for Children and Young People - Your Environment 2. The service provider should identify the source of, and eradicate, the odour within Guthrie House. NCS 5 School Care Accommodation Services - Comfort, Safety and Security NCS 4 School Care Accommodation Services - Privacy and Dignity NCS 5 Care Homes for Children and Young People - Your Environment Statement 2 We make sure that the environment is safe and service users are protected. Service strengths We found that the service had very good systems in place to ensure the safety and protection of young people. The "starting point" for this was the very positive ethos and culture within the service that focused on the establishing of effective young person/staff relationships. The service aimed to ensure that young people were "physically, socially and emotionally secure". Staff we spoke with, and observation of practice, highlighted a very good awareness of their duty to maintain safety and security. This was done discreetly, unobtrusively and effectively. Staff spoke respectfully to young people. There was a lot of good humour that young people positively responded to. Edinburgh Secure Services, page 17 of 28

18 From records we looked at, we saw that young people's safety was considered, for example, within the Care Planning Meetings, Care Plan objectives, weekly planners and LAAC reviews. Any areas of concern to the young person, including feeling safe would be discussed The physical security of the environment was very well managed. The service had a secure entry system and CCTV system. Staff were vigilant regarding visitors signing in and out and wearing "Visitor" badges. Visitors were given clear information regarding contraband and prohibited items. Lockers were provided to facilitate this prohibition. Visitors' movement between different parts of the building was supervised by accompanying staff. We saw that within the Houses, cutlery, equipment and other items were monitored effectively but discreetly. A very good staff alarm and pager system was in place and this too was managed very discreetly. Rota and on-call arrangements were very good. We saw very good shift planning. The service operated to the providers Child Protection policy and procedure. We found staff to be knowledgeable in this area and to have very good awareness of safe care issues generally. Ongoing training arrangements were in place through a City of Edinburgh Council "Child Protection Training Matrix". We found very good care and support planning and review arrangements were in place, including risk assessment. We also saw evidence of the Principle's overview of planning and review to ensure each young person continued to meet secure criteria. We found Incident and accident recording arrangements were, on the whole, very good and included overview and scrutiny from internal and external managers. The service continued to operate an analysis of incidents prepared by the Principal that allowed for very effective monitoring of and learning from, incidents. We saw that all staff were trained and updated in Crisis and Aggression Limitation and Management (CALM). The service had a Suicide Prevention Plan in place. Staff were made aware of this at team meetings and during consultations with Edinburgh Connect. The service had produced a training video for staff in action required when a young person attempted suicide. The service had recently undertaken training in Internet safety awareness involving Child Exploitation and Online Protection (CEOP). The service held a monthly Health and Safety Meeting and this was informed by, and informed, management and staff meetings where Health and Safety was a standing agenda item. The Children's Rights Officer (CRO) had a high profile within the service and was well known to young people. Both young people and staff spoke very highly of the CRO. Young people told us they knew how to access other advocacy services. Young people Edinburgh Secure Services, page 18 of 28

19 knew how to contact the Who Cares? organisation and were in regular receipt of Who Cares/ newsletters and other information. The Who Cares? worker for Edinburgh worked closely with the CROs. The CRO was notified of all incidents, including those that resulted in young people being separated from the group. The very good debriefing protocol for both staff and young people, described within the previous inspection report, remained in place. Young people told us that they trusted the staff, were able to raise any issues of concern with them and felt safe living in the service. Areas for improvement We were informed that the Night Staff Senior post had been deleted from the staffing schedule. Over recent inspections we had noted a more included, involved and motivated night staff team and had been impressed by the qualifications achieved by some members of this team. At the inspection of 18 February 201, we noted that: "The Night Staff Senior described very good night time monitoring arrangements and described his ongoing dialogue with night staff colleagues regarding balancing young people's privacy and dignity rights with their safety. The Night Staff Manager also spoke enthusiastically regarding the increased role of night staff in the overall provision of care. This included co - key working and the writing of week-end updates on each young person." The Principal described to us the new night staff supervision and management arrangements and expressed his satisfaction with them. We discussed our concerns with him and urged that night staff provision be monitored closely to ensure maintenance of this crucial aspect of the service. We will monitor this at the next inspection. We discussed with the Principal a recent incident. We were confident that he would take forward any "lessons learned" regarding information exchange at Changeover Meetings. Although we had no specific concerns regarding infection control, we discussed with the Acting Principal the good practice desirability of training staff in infection control. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 2 Recommendations Inspection report continued 1. The service and the provider, in conjunction with consultation with the Night Staff Team, should monitor the impact of having no Night Staff Senior. NCS 7 School Care Accommodation Services - Management and Staffing. Edinburgh Secure Services, page 19 of 28

20 2. The service provider should make sure that all staff have access to Infection Control training as a matter of good practice. NCS 7 Care Homes for Children and Young People - Management and Staffing. Edinburgh Secure Services, page 20 of 28

21 Quality Theme 3: Quality of Staffing - NOT ASSESSED Edinburgh Secure Services, page 21 of 28

22 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 3 - Adequate 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 did not look at all aspects of this Quality Statement. We found that the service, overall, had very good quality assurance systems in place and a culture of measuring and analysing for continued improvement. Based upon the evidence we saw, we had no concerns that serious, or potentially serious, incidents were not handled well and that the safety and wellbeing of the young people involved was being compromised. Areas for improvement As a result of regulatory activity in April 2009, the service was required to review record keeping. This was with a view to ensuring uniform recording and the use of uniform pro-forma across the service and to monitor and audit for human error. At this inspection we found some examples of poor recording practice in relation to incidents, debriefing and the administration of medicines. We also found examples where different pro-forma were in use in different Houses. We evidenced a lack of clarity regarding the service's obligation to inform the Care Inspectorate of "Notifiable" incidents as required within the "Guidance on notification reporting - All registered care services " published by SCSWIS. We discussed with the Principal what constituted an incident and a "Notifiable Incident". We received a retrospective Notification immediately following inspection from a senior member of staff. Based upon the evidence we saw, we had no concerns that serious, or potentially serious, incidents were not handled well and that the safety and wellbeing of the young people involved was being compromised. However, we were concerned that a potentially serious incident had not been recorded on the provider's required proforma and that the Care Inspectorate had not been notified. We concluded that, given the service user group, there was a risk that staff might become inured to behaviours that in a different context would be viewed as "potentially harmful". We also felt that there might be a slackness among some staff regarding recording and that this was not being identified through House Manager audit. We emphasised that we wished to work in partnership with the service in establishing agreed expectations regarding the services obligation to notify us of any "serious unplanned event that had the potential to cause harm or loss, physical, financial or material". (See Requirements 1 and 2.) Edinburgh Secure Services, page 22 of 28

23 Grade awarded for this statement: 3 - Adequate Number of requirements: 2 Number of recommendations: 1 Requirements 1. The service provider must make sure that all staff and all managers in the service fully understand Notification requirements and respond accordingly. The Care Inspectorate must be notified of all incidents as detailed within "Guidance on notification reporting - All registered care services" published by SCSWIS. This is in order to comply with: SSI 2011/28 4 (1) (b) - Records, Notifications and Returns. Timescales: the service provider must do this upon receipt of this report. 2. The service provider must make sure that: 1) staff understand what constitutes "an incident" and record accordingly. 2) there is an effective audit mechanism of detailed records by House Managers to ensure compliance with the above 3) in the immediacy, the service conducts a retrospective audit to make sure: a) incidents recorded in young people's Detailed Records have been recorded on the Provider's "Incident Form" and b) all notifiable incidents have been notified to the Care Inspectorate. This audit should cover the period from admission to the date of the audit. 4) The Principal must evidence overview/monitoring of the above, including "spot checks". The external manager should be involved in this overview/monitoring process. This is in order to comply with: SSI 2011/210 4 (1) (a) - Welfare of service users. Timescales: the service provider must do this within 4 weeks of this report being published. Recommendations Inspection report continued 1. The service provider should introduce a uniform front sheet to incident records that contains all relevant information, including de-briefing for young people and staff and provides an effective checklist of activities undertaken and if not, why not. This should allow for cross reference to other records, e.g. detailed record, single separation log, etc. NCS 6 Care Homes for Children and Young People - Feeling Safe and Secure. NCS 7 Care Homes for Children and Young People - Management and Staffing. Edinburgh Secure Services, page 23 of 28

24 NCS 7 School Care Accommodation Services - Management and Staffing Edinburgh Secure Services, 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). Edinburgh Secure Services, page 25 of 28

26 5 Summary of grades Quality of Care and Support Very Good Statement 1 Statement Excellent 5 - Very Good Quality of Environment Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Staffing - Not Assessed Quality of Management and Leadership Adequate Statement Adequate 6 Inspection and grading history Date Type Gradings 18 Feb 2011 Announced Care and support 6 - Excellent Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed 11 Aug 2010 Unannounced Care and support 5 - Very Good Environment 4 - Good Staffing Not Assessed Management and Leadership Not Assessed 10 Feb 2010 Unannounced Care and support 5 - Very Good Environment 4 - Good Staffing 5 - Very Good Management and Leadership Not Assessed 10 Sep 2009 Announced Care and support 5 - Very Good Environment 4 - Good Staffing 5 - Very Good Edinburgh Secure Services, page 26 of 28

27 Management and Leadership 5 - Very Good 12 Feb 2009 Unannounced Care and support Not Assessed Environment 4 - Good Staffing Not Assessed Management and Leadership 4 - Good 18 Nov 2008 Announced Care and support 5 - Very Good Environment 4 - Good Staffing 4 - Good Management and Leadership 3 - Adequate All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Edinburgh Secure Services, 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 SCSWIS. You can get more copies of this report and others by downloading it from our website: or by telephoning Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: enquiries@scswis.com Web: Edinburgh Secure Services, page 28 of 28