SAMH - Falkirk Support Service and Stirling Outreach Housing Support Service 2 Dunkeld Place Langlees Falkirk FK2 7TZ Telephone:

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1 SAMH - Falkirk Support Service and Stirling Outreach Housing Support Service 2 Dunkeld Place Langlees Falkirk FK2 7TZ Telephone: Type of inspection: Unannounced Inspection completed on: 1 December 2014

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 12 4 Other information 25 5 Summary of grades 26 6 Inspection and grading history 26 Service provided by: Scottish Association For Mental Health Service provider number: SP Care service number: CS If you wish to contact the Care Inspectorate about this inspection report, please call us on or us at enquiries@careinspectorate.com SAMH - Falkirk Support Service and Stirling Outreach, 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 Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well People receive support from trained, experienced and well motivated staff teams. Staff worked to ensure that people were safe, supported and that their independence was maintained. The service was well-regarded and trusted. The staff communicated very well with professionals and families, in the best interests of service users. The service was working to increase social opportunities, such as walking groups, trips and events. What the service could do better We made a small number of suggestions for improvement. In addition, a number of suggestions/requests were made by a service user. What the service has done since the last inspection The service had maintained the high standards of its service. SAMH's 'Project Maple' was reviewing polices and procedures and looking at a range of systems, travel time and paperwork, in order to help its services deliver positive outcomes for people. SAMH - Falkirk Support Service and Stirling Outreach, page 3 of 28

4 Conclusion Inspection report continued We found that the service continued to deliver very good care and support to people. SAMH - Falkirk Support Service and Stirling Outreach, page 4 of 28

5 1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Information about all care services is available on our website at This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April Requirements and recommendations If we are concerned about some aspect of a service, or think it could do more to improve, we may make a recommendation or requirement. - A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service, but where failure to do so will not directly result in enforcement. Recommendations are based on the National Care Standards, relevant codes of practice and recognised good practice. - 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 or 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 Care Inspectorate. Scottish Association for Mental Health (SAMH) is an established organisation which has provided care in the community for around 30 years. This service supports service users across the Forth Valley area from an office in Falkirk and from a registered care home in Stirling. The Registered Manager for the service is based in Falkirk. The service is available over 7 days. SAMH states it is dedicated to mental health and well-being for all. The aims and objectives of the organisation include: 'Enabling people to remain in their own homes and to exercise maximum choice and achieve optimum independence whilst ensuring that support needs are met.' At the time of this inspection there were 34 people receiving the service. Support ranged from two hours per fortnight to daily support. SAMH - Falkirk Support Service and Stirling Outreach, 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 5 - Very Good Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 5 - Very Good This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. SAMH - Falkirk Support Service and Stirling Outreach, 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 report was written following a short notice inspection on 18 November and follow on visits on 20 and 24 November Feedback was shared with the Manager and Team Leader on 24 November The service provided us with an Annual Return and Self Assessment form. We sent 35 Care Standards questionnaires to the service to distribute to service users prior to commencing the inspection. We received 8 completed questionnaires. We also sent 15 questionnaires for staff. We received 5 completed questionnaires. In this inspection evidence was gathered through: Talking to 6 service users, either in their own home, at the office or by telephone, Talking with 2 family members by telephone, Talking with the Manager, Stirling Outreach Manager, Falkirk Team Leader and a number of Support Workers. Contacting a sample of Social Workers by . We sampled records including: Quality Theme Portfolio of evidence, Service user files, support (action) plans and supporting documentation, Satisfactions survey responses, Newsletters, Photographic display of activities and events, Accident and Incident records and notes of remedial action, Staff records, Team Meeting minutes, Training records, Restraint Policy. SAMH - Falkirk Support Service and Stirling Outreach, page 7 of 28

8 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 report continued Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at SAMH - Falkirk Support Service and Stirling Outreach, page 8 of 28

9 What the service has done to meet any recommendations we made at our last inspection One recommendation was made at the previous inspection. 1. The provider should ensure that service users are offered the opportunity to retain a copy of their records within their own home. This was in accordance with the National Care Standards Housing Support Services 4 - Housing support planning. We were told that all Stirling Outreach service users had been given copies of their actions plans (personal support plans) and a record of their review meetings. In Falkirk, service users had been asked (by questionnaire) whether they wished to retain a copy of their files at home. Most had chosen not to. We recommended that service users be given copies of their actions plans and review records, as is the practice in the Stirling branch. In this way, service users can readily see what support has been agreed. We amended and carried forward this recommendation. See Quality Statement 1.1. The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. We received a fully completed self assessment document from the service. We were satisfied with the way the service had completed this and with the relevant information they had given us for each heading that we grade them under. The SAMH - Falkirk Support Service and Stirling Outreach, page 9 of 28

10 service identified what they thought they did well, some areas for development and any changes they had planned. Taking the views of people using the care service into account We spoke with six service users and received eight completed Care Standards Questionnaires. All those we heard from or spoke to said they were happy overall with the quality of their care and support. People told us: "The charity appointed by social services regularly reviews the care I receive but social services do not seem to contact me to review the care I have been receiving." "The staff at SAMH have been great with me and help me recover and understand my illness." "It's a really good service. I would like it if there could be a consistent approach from the team as to when symptoms need to be reported. I would also like a budget for social trips, such as going for a coffee out, Xmas lunch. It is very important to get out and about. I would also like it if more staff could use their cars. I raised one issue with the Manager about staff taking the lead more when I need this, for example, by saying 'come on we'll do this together' rather than waiting for me to get started." "It's excellent!they do a good job." "Top notch job." "Staff are very helpful, I decide the way things are run rather than them telling me and we come to an agreement. They phone me and clear things with me first, I am quite satisfied. There have not been too many changes. I had a review recently and I sign an agreement of what has been decided. If I didn't have SAMH I wouldn't see anybody. I know the boss and all the staff. I would be able to lift the phone and speak to (the Team Leader) if I had any problems. They are brilliant. " "It is early days. I need to get to know and trust the staff, but there is respect there." "The staff are really good. I would like more social activities. I would like to see the inspection report. I am interested in staff training." One service user made a number of suggestions for improvements to the service: SAMH - Falkirk Support Service and Stirling Outreach, page 10 of 28

11 opportunities to meet service users from other SAMH service to discuss concerns (such as benefits) and for social events, focus groups for policies, senior managers to shadow support staff to see different aspects of their job, newsletter with articles from clients an exhibition to showcase clients talents, client and support staff visiting head office, local activities e.g. walking, photography groups, less paperwork to do. Taking carers' views into account We spoke with two relatives by telephone. One Care Standards Questionnaire was completed by a relative. Comments included: "SAMH is very good, very reliable and quite flexible, for example, they can change support visits when needed. I have no problems, the staff are nice and pleasant. I sometimes meet staff at review meetings. My relative has not mentioned any issues. It is the best service she has had to date. " "My relative has been with SAMH for a few years. I contact them every few weeks or so and they are very helpful. I meet up with him every 6-7 weeks, with staff help. They take him to the shops as he is more comfortable when he has someone with him. They encourage him to do things for himself. They have some outings and they give him every encouragement. The staff would call me if there was a problem. I have every confidence in them. The only thing is that he said he was happier when there was an evening on-call service, as it was a bit of security. " "Staff are very good with my relative. Also they are there for me, to answer any questions I need to ask or if I have any problems. They say 'we are at the end of the phone' if I need to talk at any time. It is very reassuring." SAMH - Falkirk Support Service and Stirling Outreach, 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 At this inspection, we found that the performance of the service was very good in relation to participation. The organisation had a Participation Strategy for There was a leaflet advising people on 'How to be involved in SAMH'. We heard that people were encouraged to take part, but they could choose how involved they wished to be. In the Falkirk office we saw a display of photographs showing a range of events that people had taken part in during These included some social events such as trips and walks as well as: the SAMH - 'Together for Mental Health' campaign; meeting with MSP's regarding the review of the Mental Health Act; the re-branding of 'See Me'. In January 2015, people would have the opportunity to be involved in a SAMH parliamentary reception. Each service user had been provided with a handbook giving clear information of what was expected of them and what they could expect of the service. We saw that service users had been involved in providing information regarding their initial assessment. Service users were asked what they considered to be important to them and what they hoped to achieve. These discussions informed the support (action) plan. Service users were also asked about any risks and how they felt they could best be supported with these. We saw that risk assessments had been signed and dated by all parties. SAMH - Falkirk Support Service and Stirling Outreach, page 12 of 28

13 Review meetings were held very regularly and these ensured opportunities for service users and their representatives to give their views about the quality of their support. Service users confirmed that they were fully involved in these meetings. Stirling service users were given a copy of their up-dated action (personal support) plans. SAMH had a complaints policy and procedure. Service users and family members said they were confident in being able to raise issues. No complaints had been made since the previous inspection. Feedback forms were used regularly to gather the views of service users and other stakeholders about the quality of the support. We saw that the responses were very positive. SAMH kept people informed through 'Small Talk' - a quarterly newsletter. Service users had access to independent advocacy to help with decision-making and making sure that their voice was heard. Areas for improvement The Falkirk service users had been asked if they wanted a copy of their individual files. Most had chosen not to, although they knew they could access these at the office. We would expect that as a minimum, service users should be given a copy of their signed and dated action (personal support) plans, as is the practice in the Stirling branch. This is an expectation of the National Care Standards and is important so that people can they check that they are receiving the support that has been agreed. Other services we inspect share documents such as risk assessments, review meeting minutes and contact records with service users. We carried forward an amended recommendation about this. (See Recommendation 1) We heard that SAMH's National User Involvement meetings were suspended but would be re-developed. Progress in these areas will be monitored at the next inspection. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The provider should ensure that service users receive a signed and dated copy of their action (personal support ) plan. SAMH - Falkirk Support Service and Stirling Outreach, page 13 of 28

14 NCS 3 Care at Home - Your Personal Plan NCS 4 Housing Support Services - Housing Support Planning Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths At this inspection, we found that the performance of the service was very good in relation to meeting the health and welfare needs of service users. A new, standardised SAMH referral form had been introduced. We saw that the service had a 'strengths based' assessment process which took into account all of the service user's health and welfare needs. There was a health improvement checklist to prompt staff, to ensure service users got the help they needed. We saw information for staff regarding the specific mental health issues and the physical health problems that any service user had. There was evidence within support (action) plans of service users and staff working together to set goals and achieve positive outcomes. Service users had access to a range of professional people to meet their health and wellbeing needs such as GPs, CPNs, Dentists and Social Workers. Staff were aware of the importance of information sharing amongst the team and there was also evidence of excellent inter-disciplinary communication and liaison, which benefitted individuals. Staff were aware of the importance of identifying the triggers that may result in a person becoming unwell. An example of this was the "traffic light system". This was used to assist if a service user required admission to hospital. It contained appropriate information that would be helpful during a hospital admission. Staff demonstrated very good knowledge of each service user and we found there was warmth and respect for the people they were working with. The staff were highly motivated to achieve positive outcomes for people. In discussion they provided examples of what had worked well and what had been an individual success. For example we heard how music had been a 'gateway' into supporting one individual. Staff advised on the various ways they would work to assist service users with health issues. This would include a medication prompt if required. Staff would also accompany service users to appointments if the service user wished this to happen. For example, visits to the eye clinic. We also heard how support was flexible and could be re-scheduled to accommodate other appointments. SAMH - Falkirk Support Service and Stirling Outreach, page 14 of 28

15 People could choose to use support tools such as the 'My Outcomes' star which provided a visual record of progress towards their chosen outcomes. We heard that some service users liked these and others did not. Review minutes showed that people's health needs were discussed and actions updated. Incident reports detailed what had happened and any action taken. Inspection report continued Discussion with staff and service users provided strong evidence of people being encouraged and supported to develop or maintain their skills in activities of daily living in order that they were as independent as possible and to help them to reach their full potential. Service users told us about how they valued their support, especially the social time. Managers said that they had arranged befriending for service users in the past. Staff had good knowledge of other factors influencing physical and mental health such as eating well, healthy lifestyles, the effects of drugs and alcohol. One member of staff took a lead in arranging walks and was a walk leader with 'Paths of All', an organisation promoting social walking and its benefits. We heard other examples of how staff had encouraged healthy living, for example, persuading a service user to reduce their sugar intake; encouraging another service user to try something new for breakfast. Activities had included: attending art exhibitions, playing golf; table tennis; snooker, squash; going swimming; a meal out; going to the cinema; a boat trip; visiting the Kelpies; taking part in the Big Fit walk and attending a referendum debate. We heard that people had also received support to vote. Some service users had been supported to make arrangements for a holiday. One service user told us about how important it was to have personal space and how this was respected by staff. Service users were given a weekly or monthly planner for their support times and the staff member delivering their support. The Manager said that service users were telephoned if there were ay changes to this. We saw planners in people's homes and service users confirmed that these were adhered to. One service user said only once had a different member of staff turned up than who they expected. New staff were introduced to service users before they worked with them. Service users told us that they sometimes requested different staff if they found that some staff members' approach suited them better. Staff absence was managed within the team. The service did not used agency staff. SAMH - Falkirk Support Service and Stirling Outreach, page 15 of 28

16 Comments we received from professionals included: "I have worked in partnership with this agency for approximately 5 years. They are very clear about their process for referrals. When a referral is made they require quite extensive information about a client. Discussion also takes place between the worker and management. If the referral is deemed appropriate only then is an introduction meeting with the client agreed. This process allows clarity regarding what the service is able to offer the client. I have a great deal of contact with staff and management at SAMH (on average weekly). This is usually via telephone. I also visit their office and staff regularly support clients to collect money from the Social Work Office. This allows discussion and updates. Staff and management are very good at informing of any developments / issues with clients. One example of very good practice comes to mind which exemplifies the professionalism of staff....staff used their initiative, acted calmly, professionally and appropriately... It was evident that staff had undergone appropriate training, had read the risk assessments and had discussed with line managers how they would respond should they find themselves in this situation. For other clients, positive outcomes have included support to access services in the community, assistance with budgeting and dealing with debt, assistance with social isolation, support with domestic tasks, liaison Social Workers, GPs, CPNs, the Department for Work and Pensions, banks, support to attend meetings and advocacy." "There was a cohesive and easy to follow process to refer to the service. I received timely responses to questions and the Manager was free to discuss the service which was being requested. The joint visit at the client's home was organised quickly and the service began within two weeks. The service which the support worker delivers to my client is exactly what we discussed at the joint visit and it is tailored to my client. My client has expressed that the service is going very well and she feels able to communicate with the support workers easily, which is helping her to achieve her goals." "The support is in place, as agreed. Staff follow this through and if they had any concerns that a client was not keeping to this, they would be in contact. When a client relapsed they supported him in accessing the medical treatment that he required at that time. He was treated in hospital and is now back in his supported tenancy, rebuilding a structure to his week. In the past he did not have SAMH support which led to him putting himself and others at serious risk. Having support from SAMH prevented his mental state deteriorating to that extent and he was in for a brief period compared to previously... they are helping to maintain his physical and mental health at an optimum level otherwise they would deteriorate. They support him to be as independent as he possibly can and access community supports. " SAMH - Falkirk Support Service and Stirling Outreach, page 16 of 28

17 "The support my clients received was of a very high standard. The service worked very effectively to achieve the goals which were agreed with the clients and with social work in terms of promoting greater independence and autonomy and supporting clients to integrate back in to the community." Areas for improvement Having evaluated the need and previous usage, SAMH no longer offered an on-call service to service users. The Manager said that service users had been consulted before this decision was taken and that no-one raised an objection. Alternative emergency numbers had been provided. (See 'What Relatives Told Us About The Service'). We suggested that the service could check again with all service users to ensure that they have alternative contact numbers that are satisfactory to them. Progress in this area will be monitored at the next inspection. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 SAMH - Falkirk Support Service and Stirling Outreach, page 17 of 28

18 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths At this inspection, we found that the performance of the service was very good in relation to service users participating in assessing and improving the quality of staffing in the service. Service users told us about their involvement in interviewing for new staff. We heard that three service users had recently taken part in interviews and had prepared questions in advance. An example was given of how service user views about the suitability of candidates was taken into account in the decision-making process. Areas for improvement We heard that SAMH was reviewing its recruitment policy and that training for service user would be looked at. In oder to improve this grade the service could show how it offers: Service user/family involvement in staff members' performance evaluation. Involvement in the delivery of local and national staff induction and training, including at Board level. 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. SAMH - Falkirk Support Service and Stirling Outreach, page 18 of 28

19 Service strengths The service has been graded as excellent in relation to having a professional, trained and motivated staff team. This was evidenced through discussions with staff and management, service users, relatives, professionals and examination of training records. We found that staff were trained, motivated and professional. Both teams were fully qualified to the levels set out by the Scottish Social Services Council (SSSC). Support Workers Level 1 were qualified to SVQ 2. Support Workers Level 2 were qualified to SVQ 3 and they acted as keyworkers and carried a role in support planning and review. Relevant staff had registered with the Scottish Social Services Council (SSSC). New staff attended a SAMH induction and worked through a local induction checklist. There was a six month probation period. We saw a learning and development calendar for 2014/15 and a programme of core training for staff. This was available on the provider's intranet. Staff could also attend other relevant training, so that staff could meet the changing needs of service users. Staff advised on the various courses and refresher training they had recently taken part in. This included: Food hygiene; Adult Support and Protection level 3 with Forth Valley Council; Applied Suicide Intervention Skills Tuneup (ASIST); Emergency first aid; Talking About Recovery; Safe to Say frontline training; SAMH Induction training. Team meetings were held regularly. We heard that these included feedback from training attended. Communication systems (books and diaries) were used efficiently to pass on essential information between team members. Staff were seen to be very knowledgeable about service users needs and how these were to be met. Staff had regular supervision as well as very good access to managers for ad hoc advice and guidance. The Falkirk Team Leader and the Stirling Service Manager continued to provide direct support, keeping in close touch with service users and their current issues. Staff also had yearly appraisals which gave them an opportunity to reflect on their practice and professional development. Staff kept up to date with developments in mental health care, along with other relevant health conditions. The SAMH intranet flagged up when procedures were revised. Inspection report continued SAMH - Falkirk Support Service and Stirling Outreach, page 19 of 28

20 The staff demonstrated openness, teamwork and respect for each other. They confirmed that they felt there were safe working systems and supportive management on-call arrangements. Comments from staff included: "My first impressions are really good. I am really enjoying my work." "We are always floating ideas around and passing them onto service users. We mentor new staff, for example, looking over polices and procedures. We meet senior staff at training sessions. It's a great team. This year brought challenges, but it made us a stronger team. We get feedback and thanks from clients." "We have confidence in senior management. They know the pressures, they have done the job." "A good supportive team. Good communication (internally and externally). Regular supervision. Good support provided to our clients in terms of social inclusion, encouragement, advice and promoting independence and choice. Overall a great working/learning experience." "Over the past 12 months I have been supported to complete SVQ 3. SAMH has been holding monthly workshops for this at head office and I have been given dedicated time to attend all of these, as well as office time to complete my course." Comments we received from professionals included: Inspection report continued "All the staff that I have corresponded with at SAMH have been very friendly and helpful. I receive timely and good communication from them." "The staff at SAMH are very good at communicating. They will keep you updated with anything significant or information that will impact on the delivery of the clients care. They are also good at passing information on to clients as on occasions it is not always possible to contact them. Staff are very experienced workers and put the support in place, as agreed." "I found the support staff to be very caring, with a very good understanding of how to work with people with complex mental health problems. The staff communicated very well in terms of passing on any concerns immediately to me. The staff were also very efficient in forwarding documents which I requested such as copies of support plans." SAMH - Falkirk Support Service and Stirling Outreach, page 20 of 28

21 Areas for improvement Training topics identified by staff included: supervision, recruitment. Others requested annual/refresher training. We found that team meeting records were not standardised. It was not possible to see whether agreed actions had been completed. We suggested that the team meeting minutes could include a summary/action plan to clarify who should do what and by when. We also suggested a standard agenda. We heard that 'observed practice' record sheets were available but had not been used recently. Other services we inspect use these as part of the probationary process or to record observations which are referred to during staff appraisal. SAMH was preparing a response to a recent employee engagement survey. Progress in these areas will be monitored at the next inspection. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Inspection report continued SAMH - Falkirk Support Service and Stirling Outreach, page 21 of 28

22 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths We graded the service very good for this statement. There was a high level of awareness of the importance of participation and there were opportunities to influence service delivery. The Manager confirmed that she knew all of the service users. From time to time all of the managers carried out direct support work. There were opportunities for service users and families to give their views about the quality of management and leadership through regular satisfaction questionnaires. All those were talked to said that they would have confidence in raising matters with managers. SAMH encouraged service users to get involved in its forums and with its campaigns. Areas for improvement In oder to improve this grade the service could consider: Involving service users in senior staff /Board appointments. Sharing and promoting Board membership opportunities with service users and their families. Providing a link from the SAMH website to the service's inspection report. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 SAMH - Falkirk Support Service and Stirling Outreach, page 22 of 28

23 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 Inspection report continued The service had very good systems in place to assess and assure the quality of the service, including; Managers in frequent contact with service users in person and by telephone, Regular contact with relatives, Regular service user/family/other stakeholder questionnaires seeking feedback, Three or six monthly personal plan reviews, Management quality checks/audits and monitoring reports, Complaints procedure, Accident and Incident recording, with remedial action taken where required, Service user file audits, Collated reporting of service user outcomes at Board level. There was evidence of how SAMH used the above processes to ensure that the service and support offered met people's needs and expectations. For example, we heard that feedback indicated that people wanted more social activities and we saw evidence of an increase in social opportunities. One service user told us about all of the places he had visited recently and showed us photographs of these days out. We heard that service users had been able to influence the re-launched corporate strategy. SAMH's 'Project Maple' was reviewing polices and procedures, looking at systems, travel time and paperwork, in order to help services deliver positive outcomes for people. We heard that as part of the Council tendering/framework, the service would be ranked according to a range of performance measures. Comments we received from professionals included: "It is my view this agency offers an excellent service." "I have no issues with SAMH and would definitely consider using them in the future for my clients. " SAMH - Falkirk Support Service and Stirling Outreach, page 23 of 28

24 "Overall I feel that they are a very good service and I would not hesitate in placing future clients there." "Overall, I consider this service to be a well run, effective service in meeting the needs of clients with long-term mental health problems. I was impressed with the work that they do. " Areas for improvement The service had just issued the 2014 stakeholder survey. We heard that people could receive a copy of the report/analysis. We would like to see that all comments are responded to and that everyone is informed of any action to be taken. This may include saying what can and what cannot be offered and the reasons for this. For example, feedback in 2013 included a request for more staffing and a crisis service. We did not see how these suggestions for improvement had been responded to. We heard that more social time was often requested but that the service was not commissioned to provide this. (See also 'What service Users Said About the Service'). We did not see how performance and quality was monitored at Board level. We suggested that staff members might benefit from a clearer understanding of this. Progress in these areas will be monitored at the next inspection. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued SAMH - Falkirk Support Service and Stirling Outreach, 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 SAMH requested that the registered name of this service be up-dated to: SAMH - Falkirk Support Service and Stirling Outreach. Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in the Care Inspectorate re-grading a Quality Statement within the Quality of Management and Leadership Theme (or for childminders, Quality of Staffing Theme) as unsatisfactory (1). This will result in the Quality Theme being re-graded as unsatisfactory (1). SAMH - Falkirk Support Service and Stirling Outreach, page 25 of 28

26 5 Summary of grades Quality of Care and Support Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Staffing Very Good Statement 1 Statement Very Good 6 - Excellent Quality of Management and Leadership Very Good Statement 1 Statement Very Good 5 - Very Good 6 Inspection and grading history Date Type Gradings 14 Feb 2014 Announced (Short Notice) Care and support Staffing Management and Leadership 5 - Very Good 5 - Very Good 5 - Very Good 10 Oct 2012 Unannounced Care and support 5 - Very Good Staffing 4 - Good Management and Leadership 4 - Good 28 Sep 2011 Unannounced Care and support 5 - Very Good Staffing Not Assessed Management and Leadership 4 - Good 9 Dec 2010 Announced Care and support 5 - Very Good Staffing 5 - Very Good Management and Leadership Not Assessed 9 Mar 2010 Announced Care and support 5 - Very Good Staffing 4 - Good SAMH - Falkirk Support Service and Stirling Outreach, page 26 of 28

27 Management and Leadership Not Assessed 31 Mar 2009 Announced Care and support 5 - Very Good Staffing 4 - Good 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. SAMH - Falkirk Support Service and Stirling Outreach, 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: SAMH - Falkirk Support Service and Stirling Outreach, page 28 of 28