The Alpha Project Support Service Without Care at Home Muirfield Community Education Centre Brown Road Seafar Cumbernauld G67 1AA Telephone: 01236

Transcription

1 The Alpha Project Support Service Without Care at Home Muirfield Community Education Centre Brown Road Seafar Cumbernauld G67 1AA Telephone: Inspected by: Arlene Woods Type of inspection: Unannounced Inspection completed on: 22 November 2011

2 Contents Page No Summary 3 1 About the service we inspected 4 2 How we inspected this service 5 3 The inspection 12 4 Other information 20 5 Summary of grades 21 6 Inspection and grading history 21 Service provided by: The Alpha Project Cumbernauld Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Arlene Woods Telephone enquiries@scswis.com The Alpha Project, page 2 of 22

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 3 Adequate Quality of Staffing Quality of Management and Leadership N/A N/A What the service does well The service supports people to participate in activities within their community. It informs them of opportunities within and changes to the service on a routine bases. What the service could do better The service should continue to obtain service users signatures on all documents and identify their participation in all meetings. What the service has done since the last inspection The service has improved the quality of some of its policies in line with best practice guidance. Its support planning is very good with the service users and their carer involved in their development. Conclusion This service is appreciated by those who use it. It has taken guidance and changed its recording practices and policies in line with best practice guidelines. Who did this inspection Arlene Woods The Alpha Project, page 3 of 22

4 1 About the service we inspected The Alpha Project is a registered charity based in the Muirfield Community Education Centre in a residential area of Cumbernauld. The building is shared with other services and is owned by the local authority. The project provides a community support service, from Monday to Friday, for up to 45 adults with a range of physical disabilities. There were up to sixteen people using the service on the days of the inspection. The service had it's own dedicated transport, there was access to public transport and to local amenities nearby. The Service aims "to provide rehabilitation and assessment services while promoting personal independence and educational opportunities". There is a flexible programme which takes account of service user's abilities and limitations. The service was formerly registered with the Scottish Commission for the Regulation of Care (the 'Care Commission'). The Care Commission merged on 1 April 2011 with the Social Work Inspection Agency and the section of HMIE responsible for inspecting services to protect children, to form the new scrutiny body SCSWIS' 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 3 - Adequate Quality of Staffing - N/A Quality of Management and Leadership - N/A 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. The Alpha Project, page 4 of 22

5 2 How we inspected this service The level of inspection we carried out In this service we carried out a medium intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection In this service we carried out a medium intensity inspection. We wrote this report after an unannounced inspection by one inspector, which took place between 10 am and 3pm on 8/11/11 with feedback given between 10am and 1pm on 9/11/11 As requested by us, the care service sent us an annual return. The serviced also sent us a self assessment form. We issued 20 Questionnaires to friends, relatives or carers of people who used the service. 16 Questionnaires were returned before the inspection. 95% of the questionnaires returned agreed or agreed strongly that people were treated with dignity and that support needs were met. In this inspection we gathered evidence from various sources, including: * Evidence from the service's most recent self assessment * Personal plans of people who use the service * Training records * Health and safety records * Accident and incident records * Complaints records * Questionnaires that had been requested, filled in and returned to the care service from people who use the service, their relatives or advocates, and staff members * Discussions with various people, including: * the manager * care staff * the people who use the service * relatives and carers of the people who use the service * observing how staff work * examining equipment and the environment (for example, is the service clean, is it set out well, is it easy to access by people who use wheelchairs?) The Alpha Project, page 5 of 22

6 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 The Alpha Project, page 6 of 22

7 What the service has done to meet any requirements we made at our last inspection The requirement The provider must develop a policy and procedure and record-keeping system relating to restraint and produce written evidence of this to the Care Commission. This is in order to comply with: SS1 2002/114 Regulation 4 (1)(a) and (c)welfare of Users and SS1 2002/ 114 Regulation 19 (3)(a) - a requirement that a provider shall make proper provision for the health and welfare of service users and ensure that no service user is subject to restraint unless it is the only practicable means of securing the welfare of that or any other service user and there are exceptional circumstances. The provider shall keep a record of any occasion on which restraint or control has been applied to a user, with details of the form of restraint and control, the reason why it was necessary and the name of the person authorising it. Timescale for implementation - one month from receipt of this report. What the service did to meet the requirement The new restraint policy had been dated and identified the date for the policy to be reviewed. Staff interviewed were aware of their responsibilities under this policy. Support plans and risk assessments had been updated with the input form service users and their carers. Those plans we examined contained competent risk assessment and records for the use of restraints. This included wheelchair lap straps which was the most common use of restraint within the service. This requirement was fully met an will be withdrawn The requirement is: Met The requirement The provider must ensure that personal plans are used to record the needs of people who use services in all areas of their life and detail how these needs will be met. This should include how the provider intends to promote and maintain independence, health and welfare and quality of life. This is to comply with: SSI 2002/114 Regulation 2 Principles - ' a provider of a care service shall provide a service in a manner which promotes and respects the independence of service users and, so far as it is practicable to do so, affords them choice in the way the service is provided to them'. SSI 2002/114 The Alpha Project, page 7 of 22

8 Regulation 5 Personal Plans - ' a provider shall... prepare a written plan which sets out how the service user's health and welfare needs are to be met'. Timescale : Within 3 months of receipt of this report. What the service did to meet the requirement We examined 6 support plans, they had all been reviewed and held up to date support information and risk assessment for the service users. These included support needs and service users abilities including " Mrs x will tell you when she needs assistance". This requirement was fully met and will be removed. The requirement is: Met Inspection report continued The requirement The service must develop a recruitment policy which includes all best practice guidelines. SSI 2002/114 Regulation 9 2(c) Fitness of employees Regulation 19 (2)(d) Records SSI 2002/ 114 regulation 13(b) Care homes providing nursing SSSC Check criminal records & relevant registers Defined registration requirements to practice for identified titles of staff. What the service did to meet the requirement There was a recruitment policy in place which included the checking of all appropriate registers and identified when the policy should be reviewed. This requirement was fully met and shall be withdrawn. The requirement is: Met What the service has done to meet any recommendations we made at our last inspection 1. The Manager should develop a written staff development strategy and a yearly training plan for all the staff. This Recommendation is outstanding from the last report and remains unmet. National Care Standards: Support Services: Standard 2-8: Management and Staffing Arrangements. The manager has made good progress to address this recommendation with the development of a yearly staff training plan, however, a staff development strategy has not yet been put in place detailing the services future plans. The Alpha Project, page 8 of 22

9 This recommendation was partially met. 2.The Manager should survey and record if service users wish to have a lockable locker to safely store personal belongings and where they have requested one this should be provided. Anecdotally it was stated that this matter had been remitted to the members' committee but there was no evidence of monitoring of this matter. This Recommendations outstanding from the last report and remains unmet. National Care Standards: Support Services: Standard 5-6: Your Environment. The service had installed lockable storage space, this is reported under Quality statement 2:2 This recommendation has been met and will be removed 3. The Manager should ensure that care plans contain all the information recommended in the National Care Standards. This Recommendation is outstanding from the last report and remains unmet. National Care Standards: Support Services: Standard 4-7: Support arrangements. We saw that the service had made good progress in reviewing all support plans and this process is ongoing however is now at a level where we can remove this recommendation. 4. Care plans should be reviewed regularly. (NCS Support Services Standard 4-6:Support arrangements ) We saw that the service had begun review care plans, however, this was not yet completed for all service users. A regular 12 monthly review had been planned however the legislation changed in April 2011 and reviews must be less than 6 monthly. This is reported in Statement1:1 This recommendation will now be removed. 5. The service should develop a quality assurance system to demonstrate that service users, staff and carers are involved in the quality assurance process and identify issues which are raised and how these are addressed. The participation strategy, where the service users and their carers comment on the performance of the service has bedded in. The issues address within these strategies fit with those looked at by the Care Inspectorate at inspection. There was an effective system of communication and people commenting on issues which are important to this service at this time. This is mainly the moving away from a building based service to a community based service. There were audit tools in place for staff attendance, accident, incidents and complaints. The officer felt that theses systems will identify any issues which are The Alpha Project, page 9 of 22

10 detrimental to the service before they impact on the service users. This recommendation is met and will be removed. Inspection report continued 6. The manager should ask service users their view on whether the transport should advertise the service and take action on any views they may have. National Care Standards: Support Services: Standard 14-11:Daily life. There was an intention to purchase a new vehicle however this has been put on hold. The manager will consult the service users on the advertising on the new vehicle when it is back on the agenda. This recommendation has been carried over until the next inspection. 7. The service should review the recruitment and selection policy to clarify how often enhanced disclosures will be re-checked, the procedure to be followed if there are any concerns arising from disclosures, the procedure for checking professional registers i.e. SSSC, GTC and NMC and the policy should be dated. National Care Standards: Support Services: Standard 2-5:Management and staffing arrangements. The service had included in its recruitment policy the often the new Protection of Vulnerable Groups, which now takes over from the Disclosure checks should be rechecked. This recommendation had been fully addressed and will be removed. 8. The service should provide accurate, up-to-date information to existing and potential service users about the service being provided. This should include how the service will promote and maintain independence, health and welfare and quality of life. (National Care Standards Support Services 1 - Informing and deciding). The service had in place a brochure, a web page and was on facebook in order to communicate their aims and objectives and ethos to all potential and present service users. The brochure was being updated to be more descriptive of its new developments. Existing service users were to receive a copy of this brochure. This recommendation was partially met and will be carried over to the next inspection. The Alpha Project, page 10 of 22

11 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 Inspection report continued 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. Social Care and Social Work Improvement Scotland 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 headings that wed grade them under. Taking the views of people using the care service into account The staff are great" "I don't like the proposed changes but we've got to accept it" "I couldn't use a computer when I came here" "The buildings ok for what we need" Taking carers' views into account No carers were involved at this inspection as all service users were keen to complete our questionnaires. The Alpha Project, page 11 of 22

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 Overall 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 The service held regular reviews. The service had a written participation strategy which informed service users and carers of the different ways they could give their opinions to the service. It also contained the way service users and carers would be informed of what the service had done in response. The service held regular Alpha Mac meetings which were service users led. The manager was invited to attend these meetings to address specific issues. The most regular topic the manager had to answer questions on were the planned changes to the service. Sometimes the manager set part of the agenda. This was to encourage the meeting to address certain issues and help the manager obtain the information he needed to improve the service. The records show service users discussing the planned changes and that they were not happy with them, but had accepted that they were taking place. I was clear that the service users had been fully informed about shape and speed of these changes. This meeting had also addressed every statement under each theme considered in the Care Inspectorates self evaluation. This encouraged the service users to consider how they felt their service was performing and take part more effectively in the inspection process. They graded their service mostly 6s. Service users felt fully involved in the running of their service and there was evidence that they were at the time of the inspection considering what they wanted to be called as a group, for example service users or clients. There was a Complaints procedure on wall at the entrance to the service. It followed The Alpha Project, page 12 of 22

13 best practice guidelines and referred people to the Care Inspectorate. The one compliant the service had received since the last inspection had been fully investigated and the complainant responded to within the set time. The records were well maintained and audited by the manager to identify any patterns. Service user questionnaires were sent out annually. These had been broken down into topics under which the Care Inspectorate inspects the service. This helped the service identify any areas for development and use this information when completing their self evaluation document for the Care Inspectorate. Carers had separate questionnaires. These were sent out at the same time and addressed the same issues. Both sets of questionnaires had been sent out in June. The manager had reviewed the returns and recorded any suggestions for improvement from the comments. He had assessed the satisfaction rates and turned them into percentages and identified areas for improvement. The manager was developing and action plan at the time of the inspection. At the time of the inspection the manager was producing an action plan from the results and planning to use newsletter to feedback the results to service users and carers. The 3 monthly Newsletter held information telling service users and carers that the questionnaires were being sent out. We felt that this would encourage service users and carers to participate as they new all other service users were receiving them. The service sent out annual letters informing service users of the dates it was closed for public holidays, staff training and elections. It also informed service users of other policies that the service was reviewing in each months and asked for volunteer to be part of a working group to do this piece of work. The manager was aware of need to have the questionnaire evolve to address the issues of the changing service. The service had developed a facebook page, and web page to communicate with service users and potential service users. We felt that this could be helpful in attracting younger service users.. There were carers on the Alpha project board.the service provided its service users with regular feedback form the board meeting Areas for improvement All reviews should be carried out a minimum of 6 monthly. This is a new legal directive for this service (April 2011) and did not effect the grade at this inspection. (Requirement1) The Alpha Project, page 13 of 22

14 The manager had identified the need to service should develop systems which ensures all areas of the participation strategy are occurring regularly with the outcomes being identified and actioned within set timescales. Although most meetings were well recorded we felt that this could be improved. The service could develop a proforma to direct all meetings to identify who is raising and issue, who will take it forward and the outcome and timescale. Grade awarded for this statement: 5 - Very Good Number of requirements: 1 Number of recommendations: 0 Requirements 1. The service must ensure that all care reviews are held a minimum of once in 6 months. This is in order to comply with SSI2011/5 - personal plans. Timescale 8 weeks from receipt of this report Statement 2 We enable service users to make individual choices and ensure that every service user can be supported to achieve their potential. Service strengths The service had a brochure which was given to all service users before or on starting with the service. The manager was updating this to better describe the new service at the time of the inspection. All service users had a newly devised support plan which identified individual support needs. These included: service users abilities and their preferences in activities to be involved in as well as risk assessments to keep them safe. The support plans identified who should be involved in support plan reviews and when the reviews should take place. There was evidence that service users and their carers had been involved in the completion of the support plans and risk assessments. Many documents within the support plans had the signatures of the service uses and/or their carer. Areas for improvement Inspection report continued Reviews were being scheduled but for 12 months and not a maximum of 6 months. This is a new legal directive for this service (April 2011) and did not effect the grade at The Alpha Project, page 14 of 22

15 this inspection. (Requirement1) The manager was aware that not all support plans had been fully signed off by the service user and their carers and he was monitoring the development of the support plans and identifying where signatures were needed. Grade awarded for this statement: 4 - Good Number of requirements: 1 Number of recommendations: 0 Requirements 1. The service must ensure that all care reviews are held a minimum of once in 6 months. This is in order to comply with SSI2011/5 - personal plans. Timescale 8 weeks from receipt of this report The Alpha Project, page 15 of 22

16 Quality Theme 2: Quality of Environment Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths The opportunity for service users and their carers to comment on the quality of the environment are as of those listed under Quality statement 1:1. The service users we talked to did not raise any issues about the environment. The services own questionnaires reflected this opinion although some service users did think it "needed painted to freshen it up". There had been lockable lockers installed in response to the wishes of the service users. We felt this was appropriate as entry to the building was not controlled by the staff group and was shared with other services. Areas for improvement These are listed under Quality statement 1:1 Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Statement 3 The environment allows service users to have as positive a quality of life as possible. Service strengths The service had two busses which could accommodate the large wheelchairs. The building was on the ground floor with no internal stairs and good wheelchair access. The toilet facilities were able to accommodate the service users and their wheelchairs with room to move about. There were pull cords and hand rails available to promote independence. The corridors were wide as were all doorways and service users were observed moving about the building freely. The manager discussed his intentions to reduce the amount of room used by the Alpha Project and decorate and upgrade those facilities. The Alpha Project, page 16 of 22

17 Areas for improvement The alpha project is situated along one corridor of the community centre. During our inspection we noted one room being used for another community group. Other rooms along this corridor had been used by the service and had designations for example; the pottery room, the woodwork room, the computer room. These were still set up as such be we were informed they were no longer used. The two rooms used most were general purpose. The effect of this was to make the area feel empty although it was being used. We felt that reducing the number of rooms used by the service may make it feel more occupied and with an upgrade would be a pleasant base for the service to assist service users to access the community, especially over the transition period. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Inspection report continued The Alpha Project, page 17 of 22

18 Quality Theme 3: Quality of Staffing - NOT ASSESSED The Alpha Project, page 18 of 22

19 Quality Theme 4: Quality of Management and Leadership - NOT ASSESSED The Alpha Project, page 19 of 22

20 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 This inspection took account of the present aims and objectives of the service. This was a building based service and was moving slowly to becoming a community based service. The slow approach to this change was due to the service addressing the concerns of the service users and their carers. This was to reduce the anxiety caused by change, in the service user group. Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). The Alpha Project, page 20 of 22

21 5 Summary of grades Quality of Care and Support Good Statement 1 Statement Very Good 4 - Good Quality of Environment Adequate Statement 1 Statement Adequate 3 - Adequate Quality of Staffing - Not Assessed Quality of Management and Leadership - Not Assessed 6 Inspection and grading history Date Type Gradings 25 Aug 2010 Announced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 10 Dec 2009 Announced Care and support 3 - Adequate Environment 3 - Adequate Staffing 4 - Good Management and Leadership 3 - Adequate 19 Feb 2009 Care and support 3 - Adequate Environment 3 - Adequate Staffing 4 - Good Management and Leadership 3 - Adequate All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. The Alpha Project, page 21 of 22

22 To find out more about our inspections and inspection reports Read our leaflet 'How we inspect'. You can download it from our website or ask us to send you a copy by telephoning us on This inspection report is published by SCSWIS. You can get more copies of this report and others by downloading it from our website: or by telephoning Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: enquiries@scswis.com Web: The Alpha Project, page 22 of 22