Sheltered Housing Services Housing Support Service 2nd Floor Lipton House 170 Crown Street Glasgow G5 9XD Telephone:

Transcription

1 Sheltered Housing Services Housing Support Service 2nd Floor Lipton House 170 Crown Street Glasgow G5 9XD Telephone: Inspected by: Gerry Tonner Type of inspection: Announced (Short Notice) Inspection completed on: 5 March 2014

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 10 4 Other information 23 5 Summary of grades 24 6 Inspection and grading history 24 Service provided by: Loretto Housing Association Ltd Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Gerry Tonner Telephone enquiries@careinspectorate.com Sheltered Housing Services, page 2 of 25

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 Staffing 4 Good Quality of Management and Leadership 4 Good What the service does well The service offers a very good range of training opportunities for staff. We found that the service has considered national developments and best practice guidance to shape the training programme. Tenants spoken with expressed high levels of satisfaction with the day to day supports provided by staff and how this had a positive impact on their daily life. The service has involved tenants with the production of the self- assessment document which is submitted to the Care Inspectorate in advance of inspection. The service continues to hold gold status Investors in People and we found that it uses national strategies to help shape the on-going development and continuous improvement of the service. What the service could do better We have made a number of recommendations in each of the quality themes including developing a local participation strategy which reflects the range and methods that will be used to capture the views of tenants. Sheltered Housing Services, page 3 of 25

4 We found that improvements could be made with staff checking that risk assessments are re-visited post accident/incident, referrals are made for the input of professionals such as physiotherapists or falls team when there has been a deterioration of individual's mobility, support plans being reflective of the current needs and detail how supports will be offered to meet the identified needs, tenants and key people such as relatives should be involved when review meetings are carried out. Staff should be made aware of the content of key policies and procedures including whistleblowing, adult support and protection and the use of restraint. The management should ensure staff appraisals are carried out as per organisational policy. The service should develop clear records of audits carried out, have an overview in relation to review meetings and ensure that notifications are sent timeously to the Care Inspectorate. What the service has done since the last inspection The service is now part of Loretto Care a subsidiary of the Loretto Group. Loretto Care is part of the umbrella body The Wheatley Group. The service is in the process of adopting support plans to reflect the individualised supports that are provided to tenants and how positive outcomes are or will be achieved. There have been changes made to the existing management arrangements with the imminent appointment of an experienced Manager. Conclusion Based upon the findings of this inspection we concluded that the service performs at a good level in each of the quality themes that we inspected the service against. We found that the service had also identified a number of key areas that required further improvement which correlated with some of the findings from the inspection. We have reflected areas of improvement and associated recommendations throughout the report. Who did this inspection Gerry Tonner Sheltered Housing Services, page 4 of 25

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 Before 1 April 2011 this service was registered with the Care Commission. On this date the new scrutiny body, Social Care and Social Work Improvement Scotland (SCSWIS), took over the work of the Care Commission, including the registration of care services. This means that from 1 April 2011 this service continued its registration under the new body, SCSWIS. Requirements and recommendations If we are concerned about some aspect of a service, or think it could do more to improve its service, we may make a recommendation or requirement. - A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service but where failure to do so will not 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 the Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Care Inspectorate. Loretto Housing's Sheltered Housing Services provides housing support to older people in seven sheltered housing sites across Glasgow. These are located in: - Caledonia Road - Devon Street - Silverfir Court. - Kerry Lamont Avenue - St John's Court - Wyndford Drive - Lourdes Court. The a very sheltered service is also provided by the service at Jim Stephen House in Govan. The service encourages and supports tenants in their daily life. Sheltered Housing Services, page 5 of 25

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 Staffing - Grade 4 - Good Quality of Management and Leadership - Grade 4 - Good Inspection report continued This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. Sheltered Housing Services, page 6 of 25

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 A short notice inspection was carried out by Care Inspector Gerry Tonner on 18 February 2014 at the main office base. Visits were carried out on 20 February 2014 to the very sheltered housing development at Govan, a sheltered development at Toryglen and to the Cardonald development on 24 February A further visit was made to the main office on 5 March The following activities were carried out over the course of the inspection; - - Interview with 24 tenants - Reviewing 31 returned of 75 issued Care Inspectorate questionnaires - Interview with Deputy Head of Service, Registered Manager, Proposed New Manager, Team Leader, 3 Wardens (including relief warden) and Cook - Examining 3 completed and returned staff questionnaires - Checking the content of a range of documents relating to tenants including support plans, associated assessments and welfare checks - Looking at quality assurance records including audits carried out and associated action plans - Checking records associated with staff training and development records - Sampling complaint record. Feedback was given to the Deputy Head of Service, registered Manager and proposed Manager at the end of the inspection where the findings and grades awarded were accepted as an accurate reflection of current performance. 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 Sheltered Housing Services, page 7 of 25

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 Sheltered Housing Services, page 8 of 25

9 The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self assessment document from the service provider. We were satisfied with the way the service provider had completed this and with the relevant information they had given us for each heading that we grade them under. Taking the views of people using the care service into account These are reflected throughout the quality statements. Taking carers' views into account Not applicable. Sheltered Housing Services, page 9 of 25

10 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 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 Our examination of records (including returned questionnaires), discussion with tenants, carers, staff and the manager supported that the service performs a good level in this quality statement. We noted that the service has a generic Service User Participation Policy which was devised in This was complimented with A Family and Carers Involvement Strategy which details that relevant carers will be involved with the development of individual support plans and attendance to review meetings. During the inspection there were a number of "Have Your Say" meetings headed up by the Deputy Head of Service and proposed Manager with tenants in each of the developments. We attended a meeting a found that this afforded a good opportunity to share what developments and improvements were being made by the service and feedback was actively sought from tenants. We found through interviewing tenants and staff that there are many informal day to day contacts which offer opportunities for tenants to share their views. We heard that tenants found the service to be responsive in addressing concerns raised. We looked at the recently published Tenant's Newsletter dated February 14. We found that this provided information on the findings of the last satisfaction survey carried out with tenants ( ), highlighted dates for the "Have Your Say" meetings, contact details of key people within the service, updates from individual developments and sought feedback on specific areas e.g. recreational activities. We noted that tenants responded positively to the same and a number of written Sheltered Housing Services, page 10 of 25

11 suggestions had been received by the service over the course of the inspection. We found that there was a Tenant's Handbook in place at the Toryglen development which contains a useful range of information relating to local services and amenities. We thought similar publications should be made available across all of the developments. We read minutes of the Special General Meeting held in September 13 and noted that there were presentations by Chief Executive and Chairperson. We found that there was representation from tenants who currently receive the service and noted that feedback was given via a presentation on the consultation exercise on joining the Wheatley Group. The service has produced information in the format of "you said...we did..." We could see that this reflected outcomes, planned actions and timescales to address issues raised at service level. We noted that questionnaires have been used to capture individual tenants views in relation to the 3 themes covered in inspections and this information was used to shape the content of the self- assessment submitted to the Care Inspectorate. We looked at the returned Care Inspectorate questionnaires. 23 of 31 indicated that they either agreed or strongly agreed with the statement; - "The service asks for my opinions on how it can improve." We received a number of positive comments from tenants interviewed indicated that they have received surveys for completion, have been invited and attended AGM meetings and receive newsletters. New tenant visits continue to be carried out by Housing Officers. Areas for improvement Inspection report continued The Service User Participation policy makes reference to developing a local participation strategy at service level. At the point of inspection this had not been developed. We thought that it would be useful to develop this and reflect the range and methods that are used to capture the views of tenants and how this information shapes the on-going development of the service. This strategy should also reflect how the service will actively promote independent facilitation of groups and collection of views from tenants. We shall make a recommendation in connection with this area. See recommendation 1. We noted that the service misses an opportunity to capture views from individual tenants at review meetings. We shall make a recommendation in connection with this. See recommendation 2. Sheltered Housing Services, page 11 of 25

12 Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 2 Recommendations Inspection report continued 1. The service should develop a local participation strategy, reflect the methods that are used by the service to hear people's views and detail how this information will be used to shape the service. This is to comply with NCS Housing Support Standard 8 Expressing Your Views. 2. The service should routinely use review meetings to capture the views of individual tenants on the service provided. This is to comply with NCS Housing Support Standard 8 Expressing Your Views Sheltered Housing Services, page 12 of 25

13 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Our examination of records (including returned questionnaires), discussion with tenants, carers, staff and the manager supported that the service performs a good level in this quality statement. Feedback from tenants indicated that they have good response from the community alarm service and that Wardens carry out checks discreetly and as per their preferences. We received many positive comments from tenants in connection with the service and how this has had positive influences on their day to day experiences; - "I get checks each day from the warden. If I need any help or telephone numbers she gets me these." "I feel content living here, more relaxed. I would rate this as a 5 star hotel." "The warden has shown me how to work the alarm system." "I feel safe living here." "We are very happy with the support provided." We found that in some of the developments there were a range of activities that tenants could participate in. This included bingo sessions, men's group, gardening group, arts and crafts and café facility. However, these opportunities were not universally available across the developments - see comments in areas of improvement. The service has systems for overseeing accident and incident reports to identify if there are common themes or specific causes. We found that data relating to these reports feeds into the annual report. The organisation has a comprehensive range of policies and procedures to guide staff practice. We found through interviewing staff that they had a good level of knowledge relating to the needs and preferences of tenants residing within the developments visited. Areas for improvement Inspection report continued We spoke with individual tenants and checked records associated with them. We found that risk assessments were not always re-visited as per organisational policies which guide staff what actions to take post accident and incident. We shall make a Sheltered Housing Services, page 13 of 25

14 recommendation in connection with this area. See recommendation 1. We found that referrals to external professionals (such as physiotherapists) were not always being made by wardens after deterioration with individual tenant's mobility. See recommendation 2. We also thought that there could be improvements made to reflect when referrals are made, what actions were taken as a result and what was the outcome for the tenant (if known). See recommendation 2. We noted that there were very few opportunities to participate in planned activities at some of the developments. We found this to be a contrast to others which have a vibrant and active range of activities which appeared very well received by tenants. We found that the service is actively seeking feedback from tenants to find out what they may be interested in. We recognise funding of the service does not necessarily cover this area. We thought that there could be an exchange of ideas and experiences from those wardens who have had a positive influence in this area. We found that the support plans which are in two parts to be relatively generic and not particularly good for reflecting a person centred approach or encourage staff to focus on identifying and achieving positive outcomes for each tenant. We found that the service had identified this as an area for improvement in advance of the inspection. We were informed that there are plans to introduce new support plans in the coming months which have been shaped by work carried out by Joint Improvement Scotland. We shall make a recommendation that the service carries out this planned work and monitors the effectiveness of the same. See recommendation 3. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 3 Recommendations Inspection report continued 1. The service should ensure that risk assessments are up to date post accident and incident. This is to comply with NCS Housing Support Standard 4 Housing Support Planning. 2. The service should reflect clear records of when referrals are made to external professionals/organisations, actions taken and outcomes (when known) are recorded. This is to comply with NCS Housing Support Standard 3 Management and Staffing Arrangements. Sheltered Housing Services, page 14 of 25

15 3. The service should implement the new outcome focused support plans and monitor the effectiveness of the same. This is to comply with NCS Housing Support Standard 4 Housing Support Planning. Sheltered Housing Services, page 15 of 25

16 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 Our examination of records (including returned questionnaires), discussion with tenants, carers, staff and the manager supported that the service performs a good level in this quality statement. See "strengths" in quality statement 1.1. We found that there is an experienced group of staff who provide support. The tenants we interviewed were complimentary about the staff who provide the support; - "We are very happy with the supports provided by the warden." "The relief warden is excellent, she really gives you time to hear about any concerns you have." We found that there has been very little recruitment carried out since the previous inspection. However, the service arranged an informal "meet and greet" session prior to the appointment of the new Manager of the service. Details in relation to each tenant's current needs are recorded within a handover book. This is used to ensure that staff are made fully aware of current needs/issues and to ensure that there is a consistency of approach used with the staff. Areas for improvement See areas of improvement in quality statement 1.1. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Sheltered Housing Services, page 16 of 25

17 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths Inspection report continued Our examination of records (including returned questionnaires), discussion with tenants, carers, staff and the manager supported that the service performs a very good level in this quality statement. We found that there is a comprehensive training plan for staff and we found that the training plan was appropriate for the role of staff who provide support to tenants. At the point of inspection 70% of staff had achieved SVQ qualifications had obtained a recognised qualification for registration with Scottish Social Services Council (SSSC). SSSC is an organisation responsible for the registration and regulation of staff working within social care settings. We were informed that there are plans for the new Manager to attend best practice training in dementia care with a view to becoming a facilitator who will cascade the training to each staff member. We thought that this demonstrated a pro-active approach in equipping staff with necessary knowledge and skills for meeting the needs of people they support. We looked at the completed Care Inspectorate questionnaires and found that 29 of 31 indicated that they either agreed or strongly agreed with the statement; - "I am confident that the staff have the right skills to support me." We spoke with staff and looked at records associated with the Sheltered Services Review and Planning Day in October Staff shared that they found that the day was very useful for hearing about national and local developments. We found that this session was used to encourage staff to reflect and identify their strengths and areas that could be improved on. We concluded that the service promotes an open and supportive culture which encourages staff to share their views and directs them to best practice guidance. We looked at the Employee Satisfaction Survey and found that this is used to capture the views of staff against 4 main themes; - leadership, line management, employee voice and organisational integrity. The staff responses revealed that there were high levels of satisfaction of how they are managed and opportunities to share their views. We noted that the service had responded to less positive feedback by producing an action plan to address concerns raised. Sheltered Housing Services, page 17 of 25

18 We interviewed staff and found that overall they were of the opinion that there are positive working relationships with colleagues and good informal supports from line management. We looked at records associated with staff supervision. We found that these sessions are used to encourage staff to reflect on practice and to identify development and learning needs. We heard plans to have a greater focus on how staff promote positive outcomes for tenants at these sessions. We regard this as a positive development. The organisation carried out a "review of our reward, recognition and people management processes as part of the Investors in People annual review. We looked at the associated report and found that the main focus was to check if staff remain satisfied with the people management processes, if the organisation recognises and rewards staff for the work that they do. This process was also used to check how staff felt with the organisation joining the Wheatley Group. We noted that the organisation retained Gold status as an Investors in People organisation. Areas for improvement We examined returned questionnaires issued to staff and found that some of the responses indicated that some staff were unaware of key policies and procedures including restraint, whistleblowing, adult support and protection. The service should check that all staff are aware of these key policies and check their understanding of the same. We shall make a recommendation in connection with this. See recommendation 1. We checked and found that staff appraisals are not being carried out as per organisational frequency. We understood that there have been a number of priorities for the service including the service becoming part of Loretto Care which in turn has become part of the umbrella body The Wheatley Group. We thought that these factors were an influence on the delays between staff appraisals being carried out. We shall make a recommendation that staff appraisals are re-activated and carried out as per organisational policy and link identified development needs of staff to the service training plan. See recommendation 2. We found that the service has identified that training is required for staff in using and completing the new outcome based support plans. We shall check progress with this area at the next inspection. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 2 Sheltered Housing Services, page 18 of 25

19 Recommendations Inspection report continued 1. The service should check that all staff are aware of key policies including use of restraint, whistleblowing, adult support and protection and check their understanding of the same. This is to comply with NCS Housing Support Standard 3 Management and Staffing Arrangements. 2. The service should ensure staff appraisals are re-activated and carried out as per organisational policy and link the identified development needs of staff to the service training plan. This is to comply with NCS Housing Support Standard 3 Management and Staffing Arrangements. Sheltered Housing Services, page 19 of 25

20 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 Our examination of records (including returned questionnaires), discussion with tenants, carers, staff and the manager supported that the service performs a good level in this quality statement. We attended a Have Your Say meeting between tenants, Deputy Head of Service and proposed Manager. We found that this afforded a good opportunity for tenants to raise issues directly with management. We found that Management were responsive to the points raised by tenants and identified measures to address the same. See "strengths" in quality statement 1.1 and 3.1. Feedback on the quality of management and leadership has been obtained through carrying out previous surveys. Areas for improvement See areas of improvement in quality statement 1.1. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Sheltered Housing Services, page 20 of 25

21 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 Our examination of records (including returned questionnaires), discussion with tenants, carers, staff and the manager supported that the service performs a good level in this quality statement. The organisation has used national strategies and best practice guidance in the development of policies which are used to shape staff practice. We found good examples of management informing staff of government strategies and how this influences service design and how they can assist in implementing the same. Similarly the quality policy (dated March 09) details that the organisation has expectations that all staff have a responsibility in ensuring high standards of support and care are delivered and should be proactive in preventing problems occurring. See comments in relation to Investors in People status in "strengths" in quality statement 3.3. The service is a member of national bodies such as Health and Safety in Voluntary Sector Scotland and National Association for Safety and Health in Care Services. This supports that they are committed to providing a safe working environment and adhere to health and safety legislation and good practice guidance. We found that the Loretto Service Excellence and Quality Manual reflects the range of methods used both internally and externally to shape and prioritise continuous improvement. We found that the service identified key areas of improvement within the development plan. We noted that the service has produced a very detailed action plan at the Sheltered Housing Services Review and Planning Day. We could see that the action plan detailed which staff members were tasked with progressing specific areas. This demonstrated a commitment by management and staff to make improvements to the service. We examined the returned Care Inspectorate questionnaires. 30 of 31 indicated that they either agreed or strongly agreed with the statement "Overall, I am happy with the quality of care and support this service gives me." Areas for improvement Inspection report continued We noted that a number of policies and procedures were overdue for reviewing. Sheltered Housing Services, page 21 of 25

22 We shared examples of these during our feedback session. It would be appropriate that the service re-visits these now that the re-structuring has been carried out and the new manager has taken up post. The service identified within the service development plan that they need to ensure that review meetings are being carried out with each tenant as per the legislative requirements. We shall make a recommendation that a baseline is established for each development to ensure that review meetings are planned and carried out and recorded within a maximum 6 monthly interval. See recommendation 1. We were informed that there has been work carried out by a designated member of staff to audit the content of support plans and associated assessments. However, we could not see any written record that these were carried out. We shall make a recommendation that the service records when these have been carried out, identifies actions and carries out follow up actions to ensure completion. See recommendation 2. We found that information should have been sent to the Care Inspectorate following an incident which related to staff. We shall make a recommendation in relation to the service sending electronic notifications to the Care Inspectorate timeously. See recommendation 3. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 3 Recommendations 1. The service should ensure that review meetings are planned and carried out and recorded within a maximum 6 monthly interval. This is to comply with NCS Housing Support Standard 3 Management and Staffing Arrangements. 2. The service should ensure that there are clear records to reflect when audits have been carried out to support plans and associated assessments and any actions taken as a result of the audit. This is to comply with NCS Housing Support Standard 3 Management and Staffing Arrangements. 3. The service should send electronic notifications to the Care Inspectorate timeously. This is to comply with NCS Housing Support Standard 3 Management and Staffing Arrangements. Sheltered Housing Services, page 22 of 25

23 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 None. 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). Sheltered Housing Services, page 23 of 25

24 5 Summary of grades Quality of Care and Support Good Statement 1 Statement Good 4 - Good Quality of Staffing Good Statement 1 Statement Good 5 - Very Good Quality of Management and Leadership Good Statement 1 Statement Good 4 - Good 6 Inspection and grading history Date Type Gradings 16 Mar 2012 Unannounced Care and support 5 - Very Good Staffing 5 - Very Good Management and Leadership Not Assessed 2 Mar 2010 Announced Care and support 5 - Very Good Staffing 5 - Very Good Management and Leadership Not Assessed 23 Jan 2009 Announced Care and support 4 - 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. Sheltered Housing Services, page 24 of 25

25 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: Sheltered Housing Services, page 25 of 25