Moray Young Persons Supported Accommodation Service Housing Support Service Covesea Road Project Covesea Road Bishopmill Elgin IV30 4JX Telephone:

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1 Moray Young Persons Supported Accommodation Service Housing Support Service Covesea Road Project Covesea Road Bishopmill Elgin IV30 4JX Telephone: / Inspected by: Mark Causer Gordon McIntosh Type of inspection: Unannounced Inspection completed on: 20 September 2011

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 22 5 Summary of grades 23 6 Inspection and grading history 23 Service provided by: SACRO Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Mark Causer Telephone enquiries@scswis.com Moray Young Persons Supported Accommodation Service, page 2 of 24

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 3 Adequate Quality of Staffing 3 Adequate Quality of Management and Leadership 3 Adequate What the service does well The service provides support to young adults who are homeless. This is done by giving appropriate advice and support. Young people are encouraged and supported to gain skills which would help them move on to their own accommodation. Young people all commented that they were happy with the quality of care and support that they received. What the service could do better The service must ensure that staff have regular supervision and that there are regular team meetings. There was also the need for service user's meeting to occur in accordance with the statement made in the services Self Assessment. There was a need for the service to record complaints appropriately, to include an action and an outcome. What the service has done since the last inspection This was this service provider's first inspection. Conclusion The service had recently been taken over by a new provider.they were in the process of establishing their policies and a new management structure.we look forward to examining the progress of the new provider.the service had a very good strategic Moray Young Persons Supported Accommodation Service, page 3 of 24

4 plan which involved young people fully from recruitment and selection within the service to determining the future direction of the organisation. Who did this inspection Mark Causer Gordon McIntosh Moray Young Persons Supported Accommodation Service, page 4 of 24

5 1 About the service we inspected The service was registered with Care Inspectorate on 12th of May. Moray Young Persons Supported Accommodation Service is a housing support service. The service is a housing support service and the base is Covesea Road Project, Covesea Road, Bishopmill, Elgin, Moray, IV30 4JX. The service will be provided to service users in the age range of years old. The service can accommodate 10 service users at any one time. The provider has indicated that service users will be in one or more of the following categories - homeless, alcohol issues, substance abuser, chaotic lifestyle, rough sleeper, mental health, learning disabilities, family/sexual abuse, young offender/known to prison or domestic violence.the aims of the service is :- - to provide support in a homely and supportive environment where tenants have the opportunity to participate in normal patterns of daily life. - the service will enable the tenants to develop skills as appropriate, to meet their specific needs and abilities. These will vary on a daily basis and the service must be able to respond to these changing needs, e.g. support an individual to access community resources when able to provide total support within their home when required. - in a relationship based on respect, the service provider will promote a model of support that will maximise the abilities of tenants and their quality of life. The Care Inspectorate is the new regulatory body for care services in Scotland. It will award grades for services based on the findings of inspections. The history of grades that services have previously been awarded by the Care Commission will also be available on the Care Inspectorate website. All references in this report will be to the Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 ("the Regulations") (SSI 2011/210). Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 3 - Adequate Quality of Staffing - Grade 3 - Adequate Quality of Management and Leadership - Grade 3 - Adequate This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Moray Young Persons Supported Accommodation Service, page 5 of 24

6 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. Moray Young Persons Supported Accommodation Service, page 6 of 24

7 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 We wrote this report after an unannounced inspection. We visited the service 20th of August Feedback was given to the temporary manager on the 21st of August As requested by us, the care service sent us an annual return. They also sent us a very good self assessment. During the visit to the service we interviewed the 2 service users who were tenants We also interviewed three staff members. We gathered evidence from various sources, including: 6 personal support plans individual risk assessments service quality assurance material training logs complaints book service questionnaires team meeting minutes young person's meeting minutes participation strategy 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 Moray Young Persons Supported Accommodation Service, page 7 of 24

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 Moray Young Persons Supported Accommodation Service, page 8 of 24

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: No 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. A fully completed and very comprehensive Self Assessment was submitted by the service. This was completed to a high standard and gave relevant information for each of the Quality Themes and Statements. The service identified its strengths and some areas for future development and gave good evidence of service user involvement and how they planned to implement change. Taking the views of people using the care service into account The young people interviewed and those who completed questionnaires, were positive about the service, See body of this report for comments. Other comments included: "Being there when you need them which they always are". "Staff are very helpful" "My support worker has helped me and helped me understand my needs". "I am happy with the support that has been offered to me", "Nothing needs to change, nothing at all". One person identified that they had made a complaint to the service and it had not been actioned. We have informed the registered manager of this issue. There was also reference to the fact that one young person did not have a named key worker for a number of weeks. The service was aware of this situation and had recently rectified it. Taking carers' views into account No family members were spoken with at this inspection. Moray Young Persons Supported Accommodation Service, page 9 of 24

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: 3 - Adequate 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 All aspects of this quality statement were found to be met and while there are areas for improvement, the performance of the service was adequate. SACRO had recently taken over the service on 16th May The service had a number of strategies which it involved service user's in the assessment and the quality of the support they received. There was evidence that one young person meeting had taken place and the service user's indicated that this was a useful way to be involved in the improvement of the service. All young people indicated that they were fully involved in drawing up their support plans and had the opportunity to comment on the support that they received. Young people attended reviews which were held with Moray Council Housing Needs, their support worker, and any other relevant stakeholders who were also involved in the support package to the young person. Service users were also involved in the health and safety checks of their accommodation to identify any areas which may need to be replaced or renewed. Service user's had recently been involved in the selection and recruitment of permanent staff. Service users were involved in meeting and greeting candidates and also involved in the panel of service users as part of the interview process. Feedback from one young person involved indicated that this was positive. SACRO are to be commended for utilising this practice as service user's found this very beneficial. All young people interviewed were aware that there was a compliant process and compliant forms were displayed on the services noticeboard. There was also Moray Young Persons Supported Accommodation Service, page 10 of 24

11 information on advocacy services and staff interviewed indicated a good awareness of support resources in Elgin which they would support young people to attend. Areas for improvement Inspection report continued The service had created an open door policy which encouraged service users to dropin during protected time so that they could be listened to by staff members. Both young people interviewed were aware of the open door system. One stated that they felt that it was not working as it was intended, as staff were often to busy to listen to them during this protected time. It was evident from the interviews with staff and young people that several young people had lost their "Key workers" as staff had moved on from the service. This had an impact on several young people. One service user commented that the lack of a "Key worker" had made it difficult for them to attend appointments, he was extremely pleased that he now had a named person to support him. SACRO had recently appointed to the vacancies for support workers and all young people now had a named worker. We examined the complaints records. There had been one complaint received. It was evident that these records have to be developed to include, what the service did and how the outcome was communicated to the young person. (See Requirement 1) The service was in the process of creating an information pack which would contain full details of the support that young people should receive, information on external services and the complaints process. This development would be welcomed. (See Recommendation 1) There was also a need to ensure that young person meetings occurred monthly in keeping with statement made in the Self Assessment. The service had in keeping with identified a number of areas of improvement. They will be working on the following:- The development of a 360 degree review of service performance. This will include feedback questionnaires for service users and other stakeholders to be developed for use at regular intervals when a service user is receiving a service, and at point of exit. The development and use of Viewpoint an interactive online tool that allows service users to express their views on the service. A tool which will have key performance Indicators that the local authority can use to monitor and evaluation service performance. The implementation of a Performance Improvement Model. This is a working document covering all aspects of service and organisational operations and is Moray Young Persons Supported Accommodation Service, page 11 of 24

12 used in all SACRO services to monitor and evaluate service performance and improve the quality of the service. The introduction of a HOMES Matrix. The HOMES Matrix is a tool which supports service users to identify their own support needs and support plans. The service intends to review it with service users at least every three months and allows them to see areas where they are making progress. Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 1 Requirements 1. The service to keep records of any complaints made by people who use the service, representatives, relative or other person. The record should include details of the date received, issues raised, action taken, outcome the investigation, and details of how the service informed the complaint about the outcome. In order to comply:- Regulation of Care (Requirements as to Care Services) (Scotland) Regulations 2002, Regulations Timescale: Recommendations 1. The service to develop an introductory pack which clearly explains how the service works. In order to comply with:- National Care Standards Housing Support Services. Standard 1: Informing and deciding. Recommendations 1. The service to ensure that all personal plans that are developed have been signed and dated by the provider and the young person. In order to comply with :- National Care Standards Housing Support Service. Standard 4; Housing Moray Young Persons Supported Accommodation Service, page 12 of 24

13 support planning. 2. The service to ensure that all personal plans are up to date and accurate. These should be reviewed regularly within three months of starting the service. In order to comply with :- National Care Standards Housing Support Service. Standard 4; Housing support planning. Statement 4 We use a range of communication methods to ensure we meet the needs of service users. Service strengths All aspects of this quality statement were found to be met and while there are areas for improvement, the performance of the service was adequate. The service had a well established noticeboard which had information on the service. This had information on the complaints process and also how to access advocacy services and external service. The service had issued all young people with supported occupancy agreements which informed the young person of their rights and responsibilities in terms of them being a "non-tenant occupier." This also informed them of terms and conditions of their support occupancy agreement. The service also developed personal plans which identified any particular communication need and set out how the service would ensure that these needs were met. Several young people had identified learning needs and service user's interviewed indicated that these learning needs were well supported by staff. The service had well developed links with external agencies and tried to encourage young people to access these resources. Areas for improvement SACRO had recently taken over the service and had not yet achieved their identified monthly young person meeting. There was a need to ensure that these meetings occurred as young people indicated that these were essential to ensure communication between the staff and themselves. The service had an open door policy which ensured that staff were available for protected time to give support to young people. A young person interviewed indicated that this system of protected time was not working as staff often informed them that they were to busy. The manager was informed of this situation. Moray Young Persons Supported Accommodation Service, page 13 of 24

14 As already stated the service had identified the need to produce a introductory pack of information with regard to the service. This is an essential tool to ensure that the service communicates the young person rights and responsibilities. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Moray Young Persons Supported Accommodation Service, page 14 of 24

15 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths All aspects of this quality statement were found to be met and while there are areas for improvement, the performance of the service was adequate. The findings in this section are similar to those identified in Quality Theme 1, Statement 1. The service had a Service User Involvement strategy which had recently been reviewed by the organisation. The service had initiated work to involve and consult with young people to improve the service. We look forward to examining this further at future inspections. It was evident that the service had consulted with young people and invited them to take part in the recruitment and selection of new workers. Young people who were involved found this to be extremely beneficial. Areas for improvement Other areas identified for improvement are similar to those identified in Quality Theme 1, Statement 1. The service had identified the following areas for improvement :- Service user involvement in staffing and training will form a part of the Performance Improvement Model. That is being developed for the service. Viewpoint which is a feedback process developed for the young people will include questions relating to staffing. The service will develop feedback questionnaire to take account of staffing. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Statement 3 Moray Young Persons Supported Accommodation Service, page 15 of 24

16 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths Inspection report continued All aspects of this quality statement were found to be met and while there are areas for improvement, the performance of the service was adequate. The service had policies and procedures which cover all legal requirements applicable to the type of service it is providing:- recruitment health and safety 'whistle-blowing' environmental health protection of vulnerable adults child protection proper record-keeping, including recording accidents, incidents and complaints. Staff interviewed demonstrated knowledge of these and how these policies and procedures operated in practice. The service is in the process of collating a Qualification Data capture and also involving all staff in their PDR which is the provider's commitment to continuing professional development. This is at the initial stages of data collecting. We look forward to this being fully informing a training plan. All staff have to have a PDR completed by the end of October so that a training plan can be developed by the service. Areas for improvement Several staff members indicated that they had not received an induction by the service. The service had already identified the need for this support but were however awaiting all staff to be place in permanent role before this took place. This essential training is due to take part in the next few weeks. The service should ensure that induction should take place at the earliest possible venture to ensure that staff are aware of their roles and responsibilities. We noted that there had only been one formal minuted team meeting since SACRO had taken over the service. There was a need to ensure that there was regular staff meeting. (See Recommendation 1) Staff interviewed indicated that they had only received one supervision since SACRO had taken over the service. All staff should receive supervision in keeping with the organisation guidance. (See Recommendation 2) Moray Young Persons Supported Accommodation Service, page 16 of 24

17 Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 2 Recommendations 1. Team meetings to occur regularly to ensure good effective communication occurs within the service. This is in order to comply with:- National Care Standards. Housing Support Service.5.Management and staffing arrangements. 2. All staff to have regular supervision in keeping with the organisational guidance. In order to comply with:- National Care Standards. Housing Support Service.5.Management and staffing arrangements. Statement 4 We ensure that everyone working in the service has an ethos of respect towards service users and each other. Service strengths All aspects of this quality statement were found to be met and while there are areas for improvement, the performance of the service was good. Staff interviewed were committed to ensuring young people were well supported and the ethos of respect was evident from admission to moving on to a new tenancy. All young people who contributed to the Care Inspectorate questionnaires indicated that staff are extremely professional and that they worked hard at developing relationships with them based on respect. All staff were aware of the services core values of mutual respect and recognising and valuing diversity. It was evident in their practice during the inspection. Areas for improvement Inspection report continued One service user indicated that the open door policy was not working as staff were often to busy to spend any time with them. This had made the individual feel unvalued. The manager was informed of this situation. Moray Young Persons Supported Accommodation Service, page 17 of 24

18 A service user also indicated that they had made a compliant and that they had not been informed of the outcome. The manager indicated that this would be investigated. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Moray Young Persons Supported Accommodation Service, page 18 of 24

19 Quality Theme 4: Quality of Management and Leadership 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 management and leadership of the service. Service strengths All aspects of this quality statement continue to be met and while there are areas for improvement, the performance of the service was adequate. Findings for this quality statement are similar to those in Quality Theme 1, Statement 1 and Quality Theme 3, Statement 1. Although SACRO had only been operating the service since May of this year they had made a positive start to determining the strategic direction of the service. This has included the following:- Service user participation in recruitment and selection Service user involvement in training events Service profile to be developed and agreed with funder Concept of Champions of service users involvement and take innovative idea forward. Areas for improvement Other areas identified for improvement are similar to those identified in Quality Theme 1, Statement 1 and Quality Theme 3, Statement 1. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Statement 2 We involve our workforce in determining the direction and future objectives of the service. Service strengths All aspects of this quality statement were found to be met and while there are areas for improvement, the performance of the service was adequate. Moray Young Persons Supported Accommodation Service, page 19 of 24

20 Findings for this quality statement are similar to those in Quality Theme 3, Statement 3. The service was in the process of implementing the organisational strategic plan which includes;- staff surveys support and supervision team meetings forums and use of the intranet. These were yet to be fully developed and we will monitor the service's progress in future inspections. Areas for improvement The areas for improvement are the same as those identified in Quality Theme 3, Statement 3. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 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 All aspects of this quality statement were found to be met and while there are areas for improvement, the performance of the service was adequate. The service had a quality assurance process which is called the Performance Improvement Model. This is in the process of becoming operational. Once established the service will report internally and externally on the service performance at least quarterly. The service will then produce an annual report. These systems will involve young people, staff and external stakeholders. The service is also having meetings with the commissioning local authority to determine the key quality indicators which will be employed to ensure a quality provision. The service is in the process of developing a service data base which will be used to Moray Young Persons Supported Accommodation Service, page 20 of 24

21 provide information which can be used by the service to make improvements. It is to use this information to inform any development areas. The service has just recently introduced the concept of "Champions" which involved service users in the participation of offering their opinion on the strategic direction of the service. Although this service does not have a individual named Champion in this service, a similar service locally had a named Champion and they cover both services in the Moray area. Areas for improvement The service had well developed quality assurance tools. However, it is too early to comment on the effectiveness of the model. We look forward to examining the Performance Improvement Model at the next inspection. The service had identify the following improvements; Inspection report continued Full implementation of the Performance Improvement Model Establish Viewpoint and stake holder questionnaires Agree Key Performance Indicators with the local authority Develop and implement service data base, including staff training. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Moray Young Persons Supported Accommodation Service, page 21 of 24

22 4 Other information Complaints No complaints have been upheld, or partially upheld, since registered. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). Moray Young Persons Supported Accommodation Service, page 22 of 24

23 5 Summary of grades Quality of Care and Support Adequate Statement 1 Statement Adequate 3 - Adequate Quality of Staffing Adequate Statement 1 Statement 3 Statement Adequate 3 - Adequate 4 - Good Quality of Management and Leadership Adequate Statement 1 Statement 2 Statement Adequate 3 - Adequate 3 - Adequate 6 Inspection and grading history All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Moray Young Persons Supported Accommodation Service, page 23 of 24

24 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: Moray Young Persons Supported Accommodation Service, page 24 of 24

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