Battlefield ASC Day Care of Children Battlefield Primary School 44 Carmichael Place Glasgow G42 9SY Type of inspection: Unannounced Inspection completed on: 16 March 2015
Contents Page No Summary 3 1 About the service we inspected 4 2 How we inspected this service 6 3 The inspection 10 4 Other information 24 5 Summary of grades 25 6 Inspection and grading history 25 Service provided by: Battlefield ASC Management Committee Service provider number: SP2003001381 Care service number: CS2003006196 If you wish to contact the Care Inspectorate about this inspection report, please call us on 0345 600 9527 or email us at enquiries@careinspectorate.com Battlefield ASC, page 2 of 27
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 Environment 3 Adequate Quality of Staffing 3 Adequate Quality of Management and Leadership 3 Adequate What the service does well The service provides an after school service to pupils attending Battlefield Primary School. Play workers know children well and have formed good relationships with them. What the service could do better The service should address the areas for improvement and recommendations made within this inspection report. What the service has done since the last inspection A new manager has been appointed since the service's last inspection. The new manager had spent the period of time from her appointment familiarising herself with the service's policies and procedures and getting to know staff, children and families. Conclusion Children were happy and confident within the service. Staff were motivated to provide a range of activities for children. We have identified areas where the service needs to make improvements within this inspection report. Battlefield ASC, page 3 of 27
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 www.careinspectorate.com This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April 2011. Requirements and Recommendations If we are concerned about some aspect of a service, or think it could do more to improve, we may make a recommendation or requirement. - A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service but where failure to do so will not directly result in enforcement. Recommendations are based on the National Care Standards, relevant codes of practice and recognised good practice. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reforms (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. Battlefield ASC is registered to provide a day care of children service. The service operates Monday to Friday, term-time, between 3pm and 5.45pm. During school holidays, the service operates Monday to Friday between 8.30am and 5.45pm. The provider is Battlefield ASC Management Committee. The service is located within Battlefield Primary School in the southside of Glasgow and provides 40 full and part-time places for children aged 5 to 12 years. The provider aims to provide a good quality and affordable after school care service. 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 Environment - 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. Battlefield ASC, page 4 of 27
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 www.careinspectorate.com or by calling us on 0345 600 9527 or visiting one of our offices. Battlefield ASC, page 5 of 27
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 We wrote this report following an unannounced inspection that took place on 4 March 2015 between 2.45pm and 6pm and 16 March 2015 between 2.45pm and 5.30pm. One Care Inspectorate inspector carried out the inspection. Feedback and grades were given to the manager on 16 March 2015. As part of the inspection, we took account of the completed annual return and self assessment forms that we asked the provider to complete and submit to us. We sent 20 care standards questionnaires to the manager to distribute to families. Eight completed questionnaires were returned to us prior to the inspection visit. Feedback from questionnaires was shared with the manager and is documented within this inspection report. During this inspection process, we gathered evidence from various sources including the following: We spoke with: - the manager - the team leader - members of staff - children using the service - parents of children using the service - the janitor responsible for the building. We looked at: - aims and objectives - children's profiles and personal plans - administration of medication information and records - child protection policy and procedures - health and safety records - risk assessments records Battlefield ASC, page 6 of 27
- accident and incident records - infection control policy, procedures and records - complaints policy - staff files including training and appraisals records - service monitoring and evaluation systems - photographs of children participating in a range of activities indoors and outdoors. 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 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 www.firelawscotland.org Battlefield ASC, page 7 of 27
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 fully completed self assessment document from the provider. We were satisfied with the way the provider completed this and with the relevant information included for each heading that we grade service under. The provider identified what it thought the service did well, some areas for development and any changes it had planned. The provider told us how the people who used the care service had taken part in the self assessment process. Taking the views of people using the care service into account We received the following comments from children using the service. "I like playing football." "The quiet room is through there where you can read a book and relax and chill out." "I am going out to play football." "I really like doing the art and craft activities." Taking carers' views into account We received the following comments from parents whose children attend the service. "Ladies worked very hard to settle my daughter primary 2. My daughter loves the craft civilise. Security is very good. Feel I am kept up to date with what is happening, they also send texts to remind." Battlefield ASC, page 8 of 27
"I have two children using service at the moment. Very happy with it. I think a buzzer or intercom would be a good investment staff have to leave children to get the door and its a hassle." Battlefield ASC, page 9 of 27
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 After examination of relevant documents, feedback from service users, staff and management this service was found to have an adequate performance in relation to this statement. The service is run by a management committee. The management committee meet regularly to discuss all aspects of the service. The manager meets regularly with the chairperson and is involved in some management meetings. The management committee manages and maintains a Facebook page which informs parents and carers of what is going on in the service. In addition to this, termly newsletters keep parents informed of what is going on within the service. Information about the service and staff photographs were displayed for parents in the hallway. From the eight care standards questionnaires returned to us prior to the inspection, seven parents strongly agreed or agreed that the service kept them up to date with what was going on in the service through newsletters and information boards. One parent disagreed. One parent commented: "Ladies worked very hard to settle my daughter primary 2. My daughter loves the craft activities. Security is very good. Feel I am kept up to date with what is happening, they also send texts to remind." Battlefield ASC, page 10 of 27
Formal consultation had taken place with parents using questionnaires. We looked at the questionnaires that had been returned to the service. We found that parents had commented positively about the quality of the service provided. The manager had audited results from questionnaires and displayed findings in the hallway for parents. Informing parents of the results of consultation showed an ethos of partnership working and the service's willingness to involve parents in the future development of the service. We observed staff consulting and listening to children about their ideas and interests and what they would like to do. Children were confident with staff and the inspector. Children were given the opportunity to vote on what they wanted to do. Children accessed activities and resources independently throughout the session. Staff consulted with children after activities and evaluated the activities. feedback from children provided staff with information about children's likes and dislikes and enabled them to plan future activities for children. From the eight care standards questionnaires returned to us, five parents strongly agreed or agreed that the service asked their child's views about activities and outings and used their views to plan future activities. Three parents ticked don't know to this question. Areas for improvement Since the change of management, the service had not provided the same level of opportunities for children and parents to consult and be involved in improving and assessing the quality of the service offered. Previously, regular children's meeting had taken place to inform staff about changes and improvements children would like to see in the service. We found that these meeting had not taken place for some time. The service provider should reintroduce children's meetings in order to ensure that children's voices and opinions are being heard. (See Recommendation 1) Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The provider should reintroduce methods for involving children and families in improving the quality of the service provided. National Care Standards Early Education and Childcare up to the age of 16: Standard 13 - Improving the Service. Battlefield ASC, page 11 of 27
Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths After examination of relevant documents, feedback from service users, staff and management this service was found to have an adequate performance in relation to this statement. We observed children to be happy and confident in the service. Children spoke to us about their time at the service. Children enjoyed the range of activities provided by staff at the service. Some quotes from children included: "I like playing football." "The quiet room is through there where you can read a book and relax and chill out." "I enjoy doing the bubble painting and I really enjoyed the chance to be messy." Children benefitted from outdoor play on a daily basis. The school playground provided a large area for children to play freely. Ensuring that children participated in physical outdoor activity on a daily basis contributed to their health and wellbeing. From the eight care standards questionnaires returned to us, all parents strongly agreed or agreed that their child regularly got fresh air and exercise. The service provided children with healthy snacks. During the inspection visits, we observed children choosing and enjoying a healthy snack of bread, ham, cheese, grapes and buttered pancakes. A snack menu was displayed which informed children and parents of what the service provided for snacks. The service had a copy of the current best practice guidance - Setting the Table. Areas for improvement We spoke with the manager about children's personal plans. The manager informed us that she had been researching and developing appropriate personal plans for children. We sampled some children's personal plans and found that they contained limited information about children. We were particularly concerned that the service had very limited information about children with medical or additional support needs. The provider should gather information about children and use the information to develop personal plans for every child using the service. This information should be shared with staff to enable staff to fully support the individual needs of children using the service. (See Recommendation 1) Battlefield ASC, page 12 of 27
We found that the service had not administered any medication to children for some time. However information held on a child told us that the child required an inhaler. Another child's information told us that the child had a peanut allergy. There was no reference to how these medical conditions were to be managed by the service. We told the manager that she must seek written information about children's medical conditions and have clear procedures about how to deal with medical emergencies. In addition to this, we asked the manager to review the service's medication policy in line with current best practice guidelines. We signposted the manager to the Care Inspectorate document - Management of medication in daycare of children and childminding services. (See Recommendation 2) Whilst we have reported that children were happy and engaged in activities, we found that the staffing structure prevented children participating in activities that they wanted to. For example, a staff member was based outside whilst other staff members engaged with groups of children inside. We observed two children asking if they could play outdoors. A member of staff communicated with the outdoor member of staff using a walkie-talkie to enquire if the child could go outdoors. The staff member explained that the child could not go outdoors because she was at her ratio capacity. The provider should review the deployment of staff to enable all children to participate in activities they are interested in. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 2 Recommendations 1. The provider should ensure that a personal plan is in place for every child using the service. They should ensure that relevant information is sought in order to fully support children using the service. The personal plan should be developed in consultation with children and parents and be reviewed every six months or sooner if the needs of the child change. National Care Standards Early Education and Childcare up to the age of 16: Standard 6 - Support and Development. 2. The provider should review the service's policy and procedures for the safe storage, recording and administration of medicine. National Care Standards Early Education and Childcare up to the age of 16: Standard 3 - Health and Wellbeing. Battlefield ASC, page 13 of 27
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 After examination of relevant documents, feedback from service users, staff and management this service was found to have an adequate performance in relation to this statement. The strengths identified in Quality Theme 1, Statement 1, are also relevant to this statement. Areas for improvement Please see areas for improvement and recommendation made under Quality Theme 1, Statement 1. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Battlefield ASC, page 14 of 27
Statement 2 We make sure that the environment is safe and service users are protected. Service strengths After examination of relevant documents, feedback from service users, staff and management this service was found to have an adequate performance in relation to this statement. Visitors to the service gained access via the primary school. Visitors were required to sign a school visitors' book. Parents collected their children from an entrance to the dining hall. Children had access to the school dining hall, quiet room, occasional use of the school gym hall and school playground. Children used school toilets within the building. Being located within a school meant that maintenance and repairs were the responsibility of the local authority. Through speaking with the janitor, and viewing a maintenance log, we were satisfied that effective procedures were in place to ensure the safety and suitability of the premises. From the eight care standards questionnaires returned to us, seven parents strongly agreed or agreed that the service was a safe, secure, hygienic, smoke free, pleasant and stimulating environment. One parent disagreed. Children were encouraged to learn about safety and their own personal safety. Wall displays showed how children had been involved in developing golden rules to keep them safe. The manager attended local out of school care network meetings. The manager planned to visit other out of school clubs to share ideas and information. From the eight care standards questionnaires returned to us, eight parents strongly agreed or agreed that there was enough space for the children to play and get involved in a range of activities. Areas for improvement Children accessed toilets outwith the main playroom (dining room). The toilets were located along from the main entrance to the service which was unlocked. We were concerned that children went to the toilets unaccompanied. There was no evidence that the service had considered the risks of people entering the building or children visiting the toilets on their own. Battlefield ASC, page 15 of 27
In addition to this, we looked at risk assessments for the whole service. We found that these did not identify the potential hazards and risks within the environment. In order to ensure the safety of the children in the service, the provider must implement a robust risk assessment. (See Requirement 1) We found that staff had not checked or prepared children's toilets prior to the session starting. Some toilets were observed to be dirty and unhygienic with no paper towels and toilet paper placed on sinks for hand drying. In addition to this, we saw open bins overflowing with used tissues. The provider should ensure that toilets are clean and well resourced at the end of the school day prior to the session starting. (See Recommendation 1) Staff and children did not have direct access to sinks for effective hand washing. We observed staff passing anti-bacterial hand gel amongst children prior to them having snack. The use of anti-bacterial gel is only effective when used on visibly clean hands and is not a substitute for effective hand washing. We discussed with the manager the importance of effective hand washing and signposted her to the best practice guidance - Infection Prevention and Control in Childcare Settings (Health Protection Scotland). The provider should risk assess and review facilities for hand washing. (See Recommendation 2) We discussed with the manager the facilities available for the safe preparation of snacks. The manager told us that the service did not have access to the school dining kitchen for snack preparation and snacks were prepared in the playroom where there were no hand washing facilities. On our second visit, the manager informed us that she had met with the janitor to explore better food preparation areas. The service manager is currently investigating other options for snack preparation. Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 2 Requirements 1. The provider must ensure that risk assessments are carried out and that potential risks and hazards to children are identified and actions taken to minimise the risks and ensure the safety of children. Battlefield ASC, page 16 of 27
This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011 No. 210) Regulation 4(1)(a) Welfare of users. Timescale for meeting this requirement: four weeks from receipt of this report. Recommendations 1. The provider should ensure that potential risks and hazards are identified and that robust risk assessments are carried out. National Care Standards Early Education and Childcare up to the age of 16: Standard - 2 A Safe Environment. 2. The provider should ensure that appropriate toilet, hand washing facilities and supplies are available for children to carry out effective hand washing practices. National Care Standards Early Education and Childcare up to the age of 16: Standard 2 - A Safe Environment. Battlefield ASC, page 17 of 27
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 After examination of relevant documents, feedback from service users, staff and management this service was found to have an adequate performance in relation to this statement. The strengths identified in Quality Theme 1, Statement 1, are also relevant to this statement. Areas for improvement Please see areas for improvement and recommendation made under Quality Theme 1, Statement 1. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Battlefield ASC, page 18 of 27
Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths After examination of relevant documents, feedback from service users, staff and management this service was found to have an adequate performance in relation to this statement. We observed staff to be kind and caring towards children. They were motivated to provide resources and activities that children were interested in. Children were very comfortable with all staff. Staff responded, where possible, to children's requests. Staff respected children and listened to their views and opinions. Staff we spoke to enjoyed their job. They spoke about a period of transition where a new manager had been appointed. Staff worked well as a team and could identify their own training and development needs. Some staff were undertaking additional childcare qualifications. All staff had a good understanding of the service's child protection policy and understood procedures to safeguard children. Staff had participated in child protection training in February 2015. The manager had planned for all staff to undertake training. Staff told us that they took part in regular staff meetings. We saw evidence that staff received a copy of the minutes from these meetings. Staff told us that they felt the staff meetings were valuable and gave opportunities for discussion and for their ideas to be heard. From the eight care standards questionnaires returned to us, six parents agreed that staff had the skills and experience to care for their child and support their learning and development. One parent disagreed and another strongly disagreed. Areas for improvement We found that although some staff had an understanding of infection prevention and control, and the service had a copy of the best practice document, staff did not follow correct procedures to ensure that they and children carried out effective hand washing practices. We have reported on this under Quality Theme 2, Statement 2. Although staff were motivated and keen to offer a good quality of care and support to children, the layout of the service and the various age ranges limited the opportunities for children. The provider should review the deployment of staff to maximise opportunities for children. Battlefield ASC, page 19 of 27
The provider should develop and implement a training plan and training analysis for the whole staff team. Staff were keen to undertake additional training as it became available however we were not able to evidence the impact training had on the staff team or the service as a whole. (See Recommendation 1) Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service provider should develop and implement a training plan which supports staff to access relevant training to support them in their roles. National Care Standards Early Education and Childcare up to the age of 16: Standard 12 - Confidence in Staff. Battlefield ASC, page 20 of 27
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 After examination of relevant documents, feedback from service users, staff and management this service was found to have an adequate performance in relation to this statement. The strengths identified in Quality Theme 1, Statement 1, are also relevant to this statement. Areas for improvement Please see areas for improvement and recommendation made under Quality Theme 1, Statement 1. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Battlefield ASC, page 21 of 27
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 After examination of relevant documents, feedback from service users, staff and management this service was found to have an adequate performance in relation to this statement. The service manager was qualified to degree level. She had informal plans to develop the staff team and the service as a whole. The service manager had identified her training needs and acknowledged that she would benefit from additional support and mentoring. Since the inspection visits, the manager had contacted us to tell us she had discussed this with the management committee and had contacted similar services in the area to visit and share ideas and experience. The manager met with the management committee regularly. The manager was working with the committee to review policies and procedures to improve the service. The service manager and some staff told us that they had had formal supervision meetings in December 2014. We looked at supervision meetings and found that in some instances staff training needs were discussed although had yet to be actioned. The aims and objectives of the service were available to parents in the handbook with a complaints procedure and other operational policies. Areas for improvement The provider should look at how it measures the quality of the service provision and staff team. We found very little formal monitoring of the quality of the service, staff team or service as a whole took place. The service manager should implement a robust system for monitoring and evaluating the service. Although the manager was qualified to degree level, and had sought further advice by networking with similar services, it was difficult for her to implement a robust monitoring and quality assurance system due to the long periods of time she was required to work in playrooms. We found that no formal monitoring of the service had taken place since the last inspection in July 2012. (See Recommendation 1) Battlefield ASC, page 22 of 27
The service manager told us that she had not had any formal supervision or appraisal meetings with the management committee. The provider (management committee) should ensure that the work of the manager is monitored and that support and development opportunities are available to the manager. The provider should review the manager's remit. We observed, and were told by the manager, that she is often on the floor and is ratio committed. We did not feel that this was an effective use of management time. The manager should have a clear remit of her responsibilities and have sufficient time in order for her to support and develop staff and assess the quality of the care provided. (See Recommendation 2) Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 2 Recommendations 1. The provider should review the manager's remit. National Care Standards for Early Education and Childcare up to the age of 16: Standard 14 - Well-managed Service. 2. The provider should implement a robust system for monitoring and evaluating the quality of service provision. National Care Standards for Early Education and Childcare up to the age of 16: Standard 14 - Well-managed Service. Battlefield ASC, page 23 of 27
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 N/A 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). Battlefield ASC, page 24 of 27
5 Summary of grades Quality of Care and Support - 3 - Adequate Statement 1 Statement 3 3 - Adequate 3 - Adequate Quality of Environment - 3 - Adequate Statement 1 Statement 2 3 - Adequate 3 - Adequate Quality of Staffing - 3 - Adequate Statement 1 Statement 3 3 - Adequate 3 - Adequate Quality of Management and Leadership - 3 - Adequate Statement 1 Statement 4 3 - Adequate 3 - Adequate 6 Inspection and grading history Date Type Gradings 31 Jul 2012 Unannounced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good 16 Nov 2011 Unannounced Care and support 4 - Good Environment Not Assessed Staffing Not Assessed Management and Leadership 3 - Adequate 2 Dec 2010 Unannounced Care and support 4 - Good Environment 3 - Adequate Staffing Not Assessed Management and Leadership 3 - Adequate Battlefield ASC, page 25 of 27
20 May 2009 Unannounced Care and support 3 - Adequate Environment 4 - Good Staffing 4 - Good Management and Leadership 3 - Adequate 16 Jun 2008 Unannounced Care and support 3 - Adequate Environment 3 - Adequate Staffing 2 - Weak 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. Battlefield ASC, page 26 of 27
To find out more about our inspections and inspection reports Read our leaflet 'How we inspect'. You can download it from our website or ask us to send you a copy by telephoning us on 0345 600 9527. 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: www.careinspectorate.com or by telephoning 0345 600 9527. Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: 0345 600 9527 Email: enquiries@careinspectorate.com Web: www.careinspectorate.com Battlefield ASC, page 27 of 27