Rosyth Support Service - Leonard Cheshire Support Service Without Care at Home 195 Queensferry Road Rosyth Dunfermline KY11 2JH Telephone: 01383

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1 Rosyth Support Service - Leonard Cheshire Support Service Without Care at Home 195 Queensferry Road Rosyth Dunfermline KY11 2JH Telephone: Type of inspection: Unannounced Inspection completed on: 9 July 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 24 5 Summary of grades 25 6 Inspection and grading history 25 Service provided by: Leonard Cheshire Disability 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 Rosyth Support Service - Leonard Cheshire, page 2 of 27

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 4 Good Quality of Environment 4 Good Quality of Staffing 4 Good Quality of Management and Leadership 4 Good What the service does well The staff we observed appeared to know people who used the service well and people appeared comfortable and happy planning their activities for the day. What the service could do better The management team should ensure that the views of people who use the service, their families and other stakeholders are recorded and used to help review and update personal plans. The management team should also continue to develop a range of opportunities for people to be involved in assessing, developing and improving the service. What the service has done since the last inspection The staff team were working through personal plans to ensure that they contained personalised information about how they should support people who used the service. Rosyth Support Service - Leonard Cheshire, page 3 of 27

4 Conclusion The management team were making steady progress to identify areas for development and improvement. The staff team appeared motivated and enthusiastic about their jobs and family members spoke positively about the relationships that had been formed. Rosyth Support Service - Leonard Cheshire, page 4 of 27

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 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. Rosyth Support Service is a service provided by Leonard Cheshire Disability. The service is registered to provide a support service to a maximum of 12 people a day who have learning disabilities and physical and sensory impairments. The service currently operates Monday to Saturday. The service is centrally located within Rosyth and is close to local amenities and bus routes. There is a secure and secluded garden area to the rear of the building which is accessable to people with physical disabilities. Rosyth Support Service - Leonard Cheshire, page 5 of 27

6 Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 4 - Good Quality of Environment - Grade 4 - Good Quality of Staffing - Grade 4 - Good Quality of Management and Leadership - Grade 4 - 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. Rosyth Support Service - Leonard Cheshire, page 6 of 27

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 compiled following an unannounced inspection. The inspection was completed by two inspectors from that Care Inspectorate on 8 and 9 July During the inspection we gathered evidence from a variety of sources; We spoke with the Senior Support Worker and management team and observed other staff members supporting people who used the service. We also spoke informally to people who were using the service and three family members. We looked at a range of records including; Six personal plans including risk assessments, protocols and guidelines. Medication records Accident reports Results of the service user survey. Staff team meetings A sample of supervision records Training plans Managers monthly report Health and safety checks Maintenance and service records 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 Rosyth Support Service - Leonard Cheshire, page 7 of 27

8 Inspection Focus Areas (IFAs) Inspection report continued 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 Rosyth Support Service - Leonard Cheshire, page 8 of 27

9 What the service has done to meet any requirements we made at our last inspection The requirement A provider must make proper provision for the health, welfare and safety of service users. In order to achieve this,the provider must; a) ensure that medication administration records are accurate, signed and times of administration clearly recorded. b) that information recorded in personal plans is accurate and fully reflects the needs of people who use the service. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 Regulation 4 (1)(a). Timescale:- On receipt of this report. What the service did to meet the requirement Medication records were up to date and accurate. Personal plans contained information about the support that people required and referred to relevant risk assessments and protocols. The requirement is: Met - Within Timescales The requirement The provider must ensure that personal plans are reviewed at least once in every 6 month period and when there is a significant change in a service users health. Timescale:- 3 months from receipt of this report. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 Regulation 5 (2)(b)(ii) and (iii). What the service did to meet the requirement We could see that personal plans had been reviewed. It was however difficult to see how people who used the service, their families and other stakeholders had been consulted and involved. Although this requirement had been met, we restated our recommendation regarding consultation within the body of this report. The requirement is: Met - Within Timescales The requirement The provider must ensure that they provide a service in a manner which respects the privacy and dignity of service users. This is in order to comply with The Social Care Rosyth Support Service - Leonard Cheshire, page 9 of 27

10 and Social Work Improvement (Requirements for Care Services) Scotland regulations 2011 Regulation 4 (1)(b) Timescale:- On receipt of this report. What the service did to meet the requirement The provider had delivered communication training and discussed standards and values with staff in team meetings and supervision. During our inspection, staff demonstrated person centred values when working with people who used the service. The requirement is: Met - Within Timescales Inspection report continued What the service has done to meet any recommendations we made at our last inspection Recommendations made at our previous inspection have been considered within the body of the report. 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 provider. We were satisfied with the way the provider completed this and with the relevant information included for each heading that we grade services under. The provider identified what it thought the service did well, some areas for improvement and any changes it had planned. Taking the views of people using the care service into account We spoke informally with people who were using the service during our inspection. People appeared happy and relaxed and were looking forward to a range of activities supported by staff. Rosyth Support Service - Leonard Cheshire, page 10 of 27

11 Taking carers' views into account Inspection report continued We spoke with three family members. They told us that they were happy with the service and spoke positively about the current team of staff. They told us that they had opportunities to discuss support packages with staff. One family member told that staff went the' extra mile to ensure that people who used the service were supported, safe and happy.' Rosyth Support Service - Leonard Cheshire, page 11 of 27

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: 4 - 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 considered a range of evidence presented in relation to this statement. We assessed the service to be operating at a good level of performance. The provider had continued to send out an annual questionnaires to families and carers. The results of the questionnaire had been considered and the Senior Support Worker had developed an action plan. We saw that the actions identified had been discussed in a team meeting, inviting ideas for taking the action forward. For example, it was identified that communication could be improved. The staff discussed developing a regular newsletter that would be sent home with people regularly. Personal plans were in the process of being updated. The information recorded by the staff team was sent home to families and carers to ask them for their input. Family members we spoke to confirmed that they had received new plans and had contributed to them to ensure that the information was accurate and reflected the views of people who used the service and their families. Daily diaries were used as a method of communication between the staff, families and carers and other providers where appropriate. This provided an opportunity to share information, for example what activities someone had enjoyed or those that they had decided not to participate in. This information helped to plan future care and support. Rosyth Support Service - Leonard Cheshire, page 12 of 27

13 During the inspection, we saw communication books and signifiers being used with people who used the service. These were readily available to staff so that they could help people who used the service to make choices about how they would like to spend their day. We saw that staff checked with people if they wanted to continue with their planned activity for the day or if they wanted to do something else. At our last inspection we made a recommendation that people who used the service should have written agreements. We saw that these had been included in people's files and provided information about what people could expect from the service. Areas for improvement The provider should continue to develop a range of opportunities that enable people who use the service, their families and carers and other stakeholders to contribute to the assessment, development and improvement of the service. Although we thought personal plans were up to date and appeared to have been reviewed regularly, we could not see how people who used the service or their families had contributed to the plans. We were aware that plans were sent home but the feedback from families and carers was not readily available for us to see how their suggestions and views had been included. We made rewritten the recommendations made at our last inspection to consider this. (Recommendation 1 and 2) Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 2 Recommendations 1. The Provider should ensure that there is a record of the discussions and consultation that takes place when reviewing and updating personal plans. National Care Standards - Support Services - Standard 4 Support arrangements. 2. The Provider should consider how it can assess the views, opinions and preferences of people who use the service. This information should be recorded in all records and review minutes. National Care Standards - Support Services - Standard 8 - Making Choices. Rosyth Support Service - Leonard Cheshire, page 13 of 27

14 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Inspection report continued We considered a range of evidence presented in relation to this statement. We assessed the service to be operating at a good level of performance. New personal plans had been developed. These included good information about how staff should support people emotionally as well as physically. For example there was personalised detail about how someone should be supported to communicate their thoughts and feelings. This helped people to be more involved in planning their day which staff knew was important to them. Where relevant, there was guidance from other professionals available to ensure that staff had the information they needed to support people safely. For example, guidance on diets and textures of food and physiotherapy programmes that were supported by photographs. These guidelines were all clearly referenced within personal plans and risk assessments. Medication records provided clear information about the support that people required to take their medication. Staff kept good records of medication coming into the centre and going home with the person again. There were protocols in place to ensure that people received any 'as required' medication that they may require. For example, pain relief or midazolam. Staff received regular training to help them support people who used the service safely. There were regular updates of moving and handling and administration of midazolam. People who used the service enjoyed a range of activities, both within the centre and in the local community. For example, one person we spoke to was going shopping whilst another person was off horse riding. We observed positive interactions between staff and people who used the service. We spoke informally with people who used the service and with some family members. Everyone appeared positive about the staff group and told us that staff did all they could to ensure that people who used the service were supported, safe and happy. Rosyth Support Service - Leonard Cheshire, page 14 of 27

15 Areas for improvement The Senior Support Worker (SSW) and the staff team had worked hard to develop the person centred plans. The SSW told us that they aimed to have all the plans of the same standard as the good examples that we saw. The staff team should continue to work with people who use the service and their families to ensure that this work is completed as a priority. The staff must ensure that they maintain records of consultation with people when reviewing personal plans. (See 1.1) Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Rosyth Support Service - Leonard Cheshire, page 15 of 27

16 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 Evidence considered in relation to this statement is reported under Quality Theme 1 Statement 1. Areas for improvement See Quality Theme 1 Statement 1. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Rosyth Support Service - Leonard Cheshire, page 16 of 27

17 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths We thought the service had maintained a good level of performance in relation to this statement. The environment was clean and accessable. During the inspection, good use was being made of all areas within the building which helped to ensure that rooms were not over crowded and that there were quiet areas for people to enjoy. We observed positive interactions between staff and people who used the service. Communication books and signifiers were available to help people communicate their feelings and thoughts. There was good information in personal plans that helped staff to support people in a person centred manner. For example, there was information that helped staff to assess if someone was in pain or uncomfortable and what they should do to help them. Staff had received a range of training that supported them in their roles. This helped them to understand and respond appropriately to the needs of people who used the service. There were protocols and guidelines from other professionals that helped staff to ensure that they could support people safely. For example, guidelines on diet and textures of food and physiotherapy guidelines. This helped staff to have a consistent approach to ensuring that people were supported in a safe, consistent manner. The staff carried out a range of environmental checks to ensure that the building was well maintained and safe. Areas for improvement Inspection report continued People who used the service had access to a bed when being assisted with personal care. The mattress cover was damaged which increased the risk of infection or cross contamination. The provider was aware of this and had requested a new one. This should be given priority to ensure that any risks are minimised for people who use the service. (Requirement 1) The management team told us that they had a plan for redecoration of the building. This would be an ideal opportunity to involve people who used the service in planning and considering how they could improve the environment. Rosyth Support Service - Leonard Cheshire, page 17 of 27

18 Grade awarded for this statement: 4 - Good Number of requirements: 1 Number of recommendations: 0 Requirements 1. The Provider must ensure that all equipment used is in a good state of repair. In particular, the Provider must replace the damaged mattress observed during the inspection. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 SSI 2011/210 Regulation 4 (1)(d) Timescale: Within 1 week of receipt of this report Rosyth Support Service - Leonard Cheshire, page 18 of 27

19 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 evidence considered in relation to this statement is reported under Quality Theme 1 Statement 1. Areas for improvement See Quality Theme 1 Statement 1. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Rosyth Support Service - Leonard Cheshire, page 19 of 27

20 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths We considered a range of evidence presented in relation to this statement. We assessed the service to be operating at a good level of performance. During our inspection, the service was without a registered manager. A senior support worker was taking the lead role in developing and improving the service. The staff team were also being supported by the wider management team. The SSW had made good progress to progress areas of development and improvement that they had identified. Staff had regular team meetings. Minutes of these demonstrated a wide range of topics discussed. The wider management team also attended these meetings periodically and encouraged staff to express their opinions and to make suggestions for the improvement and development of the service. Staff had received a range of training that supported them in their roles. Where relevant, there were regular updates of training, for example in moving and handling and the administration of midazolam. This helped staff maintain their skills and knowledge for supporting people. Staff had supervision with their line manager regularly. This provided an opportunity for staff to discuss their training and development needs as well as the development of the service. Areas for improvement The SSW had identified that annual appraisals for staff were overdue. This forum along with supervision meetings will help the manager to consider individual training needs for staff and will influence an annual training plan. The manager should consider how the views of people who used the service, their families and other stakeholders can be used to inform the development of the staff team. The Provider should continue with their recruitment process to appoint a permanent manager. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Rosyth Support Service - Leonard Cheshire, page 20 of 27

21 Quality Theme 4: Quality of Management and Leadership 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 management and leadership of the service. Service strengths The evidence considered in relation to this statement is reported under Quality Theme 1 Statement 1. Areas for improvement See Quality theme 1 Statement 1. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Rosyth Support Service - Leonard Cheshire, page 21 of 27

22 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 considered a range of evidence presented in relation to this statement. We assessed the service to be operating at a good level of performance. The Provider had systems in place to allow the management team to have an overview of the service. These systems included; The SSW completed monthly reports that were sent to their service manager. This included an overview of the service - general information about what was happening during the month. Any issues were described and actions taken to resolve or address these, staffing concerns for example any vacancies or absences as well as progress with new staff induction programmes. We saw that the SSW used this report to consider developments and improvements within the service and there was a regular update of progress they were making. Team meetings and staff supervision meetings provided an opportunity for staff to participate in the assessment of the service. The provider continued to carry out annual surveys to canvas the views of people who used the service and their families about how the service could develop or improve. For example the most recent survey had identified that communication with families could be improved. The staff were considering how they could develop a regular newsletter to ensure that people were kept up to date. Personal plans were sent home to families so that they could contribute to the information that they contained or make changes if necessary. Areas for improvement The manager should ensure that they keep a record of discussions they have had with people who use the service, their families and carers and other stakeholders when reviewing personal plans. The management team should consider the development of a service improvement and development plan. This can be a useful tool in identifying areas for development and prioritising for the year ahead. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Rosyth Support Service - Leonard Cheshire, page 22 of 27

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24 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 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). Rosyth Support Service - Leonard Cheshire, page 24 of 27

25 5 Summary of grades Quality of Care and Support Good Statement 1 Statement Good 4 - Good Quality of Environment Good Statement 1 Statement Good 4 - Good Quality of Staffing Good Statement 1 Statement Good 4 - Good Quality of Management and Leadership Good Statement 1 Statement Good 4 - Good 6 Inspection and grading history Date Type Gradings 15 Aug 2013 Unannounced Care and support 3 - Adequate Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 4 Aug 2010 Announced Care and support 6 - Excellent Environment Not Assessed Staffing Not Assessed Management and Leadership 5 - Very Good 4 Mar 2010 Announced Care and support 5 - Very Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed Rosyth Support Service - Leonard Cheshire, page 25 of 27

26 11 Dec 2008 Announced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Rosyth Support Service - Leonard Cheshire, page 26 of 27

27 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: Rosyth Support Service - Leonard Cheshire, page 27 of 27