Joans Carers Ltd Housing Support Service 29 Grant Street Helensburgh G84 7QN Telephone:

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1 Joans Carers Ltd Housing Support Service 29 Grant Street Helensburgh G84 7QN Telephone: Inspected by: Kevin Dale Type of inspection: Unannounced Inspection completed on: 2 February 2012

2 Contents Page No Summary 3 1 About the service we inspected 4 2 How we inspected this service 5 3 The inspection 8 4 Other information 14 5 Summary of grades 15 6 Inspection and grading history 15 Service provided by: Joans Carers Ltd Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Kevin Dale Telephone enquiries@scswis.com Joans Carers Ltd, page 2 of 16

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 Joans Carers continues to provide a good quality and valued service to service users. The manager does her best to ensure that the continuity of support is consistent by using the same staff teams for service users. Responses from service user questionnaires evidenced that there is satisfaction with the service. What the service could do better The service continues to develop the quality assurance systems and ways to improve consultation with service users and relatives. What the service has done since the last inspection Service user support plan recordings had improved and staff had more access to training opportunities. Conclusion The service continues to provide a good quality service and continues to look at ways to continuously improve the service delivered to service users. Who did this inspection Kevin Dale Lay assessor: Not Applicable Joans Carers Ltd, page 3 of 16

4 1 About the service we inspected Joans Carers is a privately owned organisation which provides personal care and domestic support to a range of vulnerable adults in Helensburgh, Dumbarton and the surrounding areas. The service was registered by the Care Commission on 1st September The aims and objectives of the service were stated as: Preserve and respect the clients dignity and treat with courtesy and honesty at all times. Help the client achieve and sustain the maximum possible independence in their chosen environment. Include the client in decision making thus making sure they have enough information to make informed choices. Treat clients on the basis of need and not on the basis of age, sex, race, religious beliefs, disability or sexual orientation. 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 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. Joans Carers Ltd, page 4 of 16

5 2 How we inspected this service The level of inspection we carried out In this service we carried out a low intensity inspection. We carry out these inspections when we are satisfied that services are working hard to provide consistently high standards of care. What we did during the inspection This unannounced inspection took place on the 2 February 2012 and was conducted by Care Inspectorate Inspector Kevin Dale. During the course of the inspection we looked at: The operational development plan Staff and Service user questionnaires Staff meeting minutes Service user files including care plans, reviews of their service and daily running notes The service's self assessment Communication evidence with service users and staff Staff files including recruitment documentation The services training plan The services questionnaire "How are we doing" and the Action plan from this with the evidence of actions taken Staff Memos Staff work sheet and Rota The registration Documentation 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 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 Joans Carers Ltd, page 5 of 16

6 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 Joans Carers Ltd, page 6 of 16

7 The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. We received a completed Self Assessment that told us what the service did well and areas for improvement. We discussed with the manager the benefit of including service users' comments with the self assessment. Taking the views of people using the care service into account We sent 20 Care Standard Questionnaires to service users and relatives and 3 were returned, comments included: "Joans Carers provided a sheet weekly for the clients info who was the carer, time etc for each day. For some reason this service has been stopped and I find it rather inconvenient" "It would be more satisfactory if the same person could come on a regular basis instead of a different person almost every day" The 3 respondents stated that overall they agreed that they were happy with the quality of care and support the service offered. Taking carers' views into account One relative stated that overall they strongly agreed that they were happy with the quality of care and support the service offered. Joans Carers Ltd, page 7 of 16

8 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 The manager reported that joint care reviews were taking place with Social Work Care Managers and that the frequency of reviews had improved over the last 6 months. Areas for improvement The manager stated that minutes of Social Work Review meetings were not always sent to the service. We advised the manager that she should take her own review minute for reference. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 3 We ensure that service user's health and wellbeing needs are met. Service strengths We looked at service users' support plans and found that reviews were taking place and that support plans were updated to reflect the outcome of reviews. Staff are informed of changes to support plans verbally and memos. The manager tries to ensure that the same team of staff are used to support individual service users. Staff report that they support mostly the same service users every week. Service user support plans daily notes contained good information on tasks undertaken, meals prepared and the service users wellbeing. Support plans are held in service users' homes and a copy in the office. Joans Carers Ltd, page 8 of 16

9 Areas for improvement The manager stated that they provide a rural service but the Social Work contract did not include travel time. Some service users are unhappy that the duration of home visits is reduced because of this. The manager and staff try to ensure that service users' needs are met within the time allocated for each visit. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Joans Carers Ltd, page 9 of 16

10 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 Service user questionnaires asked service users for their views on the quality of staff. The manager uses the questionnaires to inform the service development plan. Responses from questionnaires indicated that service users were very satisfied or satisfied with the quality of the service. Areas for improvement Service user questionnaires are sent out twice yearly, the manager reported that response had decreased because service users state they are being asked to complete too many questionnaires from the Council and the service. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths We spoke to staff and reviewed staff training files. We found evidence of staff undertaking 1 weeks induction training before they commenced work and shadowed experienced support staff before working on their own. Some staff had recently undertaken training in adult support and protection, managing challenging behaviour and moving and handling. The manager has arranged training via James Watt Collage in dementia care, palliative care and medication administration. Some staff were currently undertaking vocational qualifications in care. Staff appraisals take place usually on a 6 monthly basis. Staff have a personal development plan and complete a training questionnaire. Joans Carers Ltd, page 10 of 16

11 Areas for improvement Currently there are 8 staff trained to administer medication, we discussed with the manager the importance of having a system in place to assess staff competency for medication administration. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Joans Carers Ltd, page 11 of 16

12 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 Staff satisfaction questionnaires evidenced that on the whole staff are satisfied with the service they provide. Some responses indicated that staff felt there was not enough time to spend with service users. Staff are able to contribute and comment on the service development plan via appraisal meetings and questionnaires. Areas for improvement The manager reported that staff meetings should take place on a 2 monthly basis, however they are not that well attended. Grade awarded for this statement: 5 - Very Good 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 Responses from staff questionnaires and discussions with staff indicated that they felt supported by management and were able to discuss any concerns they had. We found evidence of 'spot checks' and observation of staff care practice taking place to assure the quality of the support provided. The manager has quality assurance tools and undertakes a quarterly audit of the service. We advised that it would be good practice to include an outcomes section in the operational action plan. Joans Carers Ltd, page 12 of 16

13 Areas for improvement We advised the manager that it was good practice to include the office telephone number on staff identification badges for verification purposes. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Joans Carers Ltd, page 13 of 16

14 4 Other information Complaints No complaints have been upheld, or partially upheld, since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in 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). Joans Carers Ltd, page 14 of 16

15 5 Summary of grades Quality of Care and Support Good Statement 1 Statement Very Good 4 - Good Quality of Staffing Good Statement 1 Statement Very Good 4 - Good Quality of Management and Leadership Good Statement 1 Statement Very Good 4 - Good 6 Inspection and grading history Date Type Gradings 18 Aug 2010 Announced Care and support 4 - Good Staffing Not Assessed Management and Leadership 4 - Good 8 Mar 2010 Announced Care and support 3 - Adequate Staffing 3 - Adequate Management and Leadership 3 - Adequate 19 Jan 2009 Announced Care and support 3 - Adequate Staffing 3 - Adequate 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. Joans Carers Ltd, page 15 of 16

16 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: Joans Carers Ltd, page 16 of 16