Care service inspection report Full inspection Caledonia Housing Support Services Housing Support Service 118 Strathern Road Broughty Ferry Dundee Inspection completed on 08 March 2016
Service provided by: Caledonia Housing Association Limited Service provider number: SP2012011850 Care service number: CS2012308789 Inspection Visit Type: Unannounced Care services in Scotland cannot operate unless they are registered with the Care Inspectorate. We inspect, award grades and set out improvements that must be made. We also investigate complaints about care services and take action when things aren't good enough. Please get in touch with us if you would like more information or have any concerns about a care service. Contact Us Care Inspectorate Compass House 11 Riverside Drive Dundee DD1 4NY enquiries@careinspectorate.com 0345 600 9527 www.careinspectorate.com @careinspect page 2 of 34
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 Quality of staffing 4 Quality of management and leadership 4 Good Good Good What the service does well The manager and staff in the service demonstrated a commitment to providing a quality service that met the support needs of the people who access the service. People who used the service were supported to maintain their independence within a sheltered housing complex. The service users spoken with during the inspection visits spoke highly of the staff supporting them. We also received positive responses in completed Care Inspectorate Care Standards Questionnaires (CSQs) about the difference, support from the service had made to people's lives. Comments made have been recorded throughout this inspection report. What the service could do better The management team should continue to develop the quality assurance,audit and control systems, to ensure they are effective in informing and improving practice. Personal plans could be further developed to clearly identify how identified outcomes were to be achieved. Risk assessments should evidence service users' involvement, in identifying risks and agreement of how these were to be page 3 of 34
managed. All fields should be completed. The service should review the Adult Support and Protection (ASP) policy and ensure all staff receive appropriate ASP training. The service should review the system of supervision and appraisal to ensure it is fit for purpose going forward. The way in which the service demonstrates staff development and training could be better. Staff should have access to the latest up to date training available e.g. 'Promoting Excellence'. What the service has done since the last inspection This was the second inspection of the Housing Support Service since becoming independent of the Care at Home element, also provided by Caledonia Housing Association Limited. The division made each element of the service more manageable and allowed the registered manager for the Housing Support Service to focus their attention on the continuing development of the service. It should be noted that while the Housing Support Service continues to expand, the organisation may need to look at the management structure to ensure the good performance identified at this inspection, can be maintained and improved further. We were pleased to hear that the service was currently developing a new person-centred outcome focussed care plan. We look forward to seeing how this is progressing at the next inspection. The service has appointed a new manager since the last inspection and we found the manager to be enthusiastic and committed to improving the service. page 4 of 34
Conclusion Caledonia Housing Support Service provides a highly valued and respected service, which provides people with the opportunity to remain as independent as possible within their own home. Overall, people using the service were very happy with the service they receive. page 5 of 34
1 About the service we inspected Caledonia Housing Association formed in 2011 following the merger of Servite and Perthshire Housing Associations. They are a registered Scottish Charity and their main aim is to provide high quality housing that is both affordable and sustainable, with a variety of specialist and person-centred services. The association operate throughout Dundee, Angus, Perthshire and Fife, and in the Highland Council area. With around 4,000 properties in their ownership and management. They cater for many diverse needs, offering mainstream housing for families, couples and single people, as well as supported accommodation, sheltered housing, residential care and amenity, and other specially adapted properties, including those specifically designed for wheelchair users. They are governed by a voluntary management board on a day-to-day basis. Their activities are carried out by a paid staff team. Their stated guiding principles are as follows: "Our principles are central to what we do and incorporate the importance that we place on people, value and quality. - Excellence: we will strive for excellence in all that we do. - Customer Service: providing great customer service will be at the heart of our work. - Respect: we will respect the diverse nature of our customers, their individual needs and the communities where they live. - Integrity: we will be open, honest and accountable in all aspects of our work." Recommendations A recommendation is a statement that sets out actions that a care service provider should take to improve or develop the quality of the service, but where failure to do so would not directly result in enforcement. page 6 of 34
Recommendations are based on the National Care Standards, SSSC codes of practice and recognised good practice. These must also be outcomes-based and if the provider meets the recommendation this would improve outcomes for people receiving the service. Requirements A requirement is a statement which sets out what a care service must do to improve outcomes for people who use services and must be linked to a breach in the Public Services Reform (Scotland) Act 2010 (the "Act"), its regulations, or orders made under the Act, or a condition of registration. Requirements are enforceable in law. We make requirements where (a) there is evidence of poor outcomes for people using the service or (b) there is the potential for poor outcomes which would affect people's health, safety or welfare. 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 www.careinspectorate.com or by calling us on 0345 600 9527 or visiting one of our offices. page 7 of 34
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 The inspection was carried out by one inspector on Monday 7 March 2016 between the hours of 10.00 am and 17.00 pm this continued on Tuesday 8 March 2016 between the hours of 10.00 am to 17.35 pm. Feedback was given to the Head of Support and the Manager on 8 March 2016. As part of the inspection a visit was made to a sheltered complex in Dundee on Tuesday 8 March 2016. We issued twenty Care Inspectorate questionnaires (CSQs) and received five completed CSQ's before the inspection. We also received four completed staff CSQ. During the inspection process we gathered evidence from various sources, including: We looked at: - The service policies and procedures - The service's most recent self assessment - Support plans and other relevant documentation for the people who use the service - Minutes of staff meetings - Minutes of service user meetings - Staff training and supervision records - Accident and incident reports - Registration and insurance certificates - Completed audits. page 8 of 34
We spoke with: - The service manager - The head of support - One scheme manager - Six service users. 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 prior to the inspection visits. Our findings from the above sources informed this inspection report. 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.firescotland.gov.uk page 9 of 34
The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self-assessment document from the provider. We were satisfied with the way the service provider had completed this and with the relevant information they had given us for each of the headings that we grade them under. The provider identified what they thought they did well, some areas for development and any changes it had planned. The service 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 issued twenty Care Inspectorate questionnaires (CSQs) and received five completed CSQ's before the inspection. Three people who completed a Care Inspectorate questionnaire, or completed one on behalf of a service user, strongly agreed or agreed that overall they were happy with the quality of care and support this service gave them. Two people indicated that the question was not applicable. Four people indicated that they did not know about the services complaints procedure or that they could make a complaint to the Care Inspectorate. One person disagreed when asked in they has a personal care plan. One person disagreed that the service asks their opinions on how it can improve. page 10 of 34
We did not receive any comments in the completed and returned CSQs. Taking carers' views into account We issued twenty Care Inspectorate questionnaires (CSQs) and received five completed CSQ's before the inspection. Three people who completed a Care Inspectorate questionnaire, or completed one on behalf of a service user, strongly agreed or agreed that overall they were happy with the quality of care and support this service gave them. Two people indicated that the question was not applicable. Four people indicated that they did not know about the services complaints procedure or that they could make a complaint to the Care Inspectorate. One person disagreed when asked in they has a personal care plan. One person disagreed that the service asks their opinions on how it can improve. We did not receive any comments in the completed and returned CSQs. page 11 of 34
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 strengths and areas for improvement discussed under this Quality Statement also apply to Quality Theme 3, Quality Statement 1 and Quality Theme 4, Quality Statement 1. During our inspection, we found the service to evidence a good performance in the areas covered by this Quality Statement. We came to this conclusion after looking at personal support plans; reviewing policy/procedures (and how these were used); and talking to people who use the service, staff and managers. From this evidence we were satisfied that a number of methods were employed to encourage those who used the service, to participate in assessing and improving the quality of the service. These included: - A participation strategy promoting ongoing involvement with service users and other stakeholders in relation to how the service is run. page 12 of 34
- Involvement in the development of individual support plans and six-monthly review meetings. - Regular service user meetings. People we spoke with confirmed these meetings took place and said their views were listened to. - Service users confirmed they had regular access to scheme managers to discuss any matters relating to the support they received. - Annual satisfaction survey to gain the views of people in receipt of the service about the service provision and the opportunity to attend the annual conference of the organisation. - The production of a quarterly newsletter. Service users were provided with a tenancy handbook when they started using the service. This set out their responsibilities as tenants and what they could expect from the service. The organisation displayed information on how to make a complaint, including how to complain to the Care Inspectorate. Information about the service and the organisation was available on the service's website and within the sheltered complex. All new service users received a welcome pack containing information about the service provided and included the organisation's complaint procedure. The organisation employs two part-time participation officers (this is a statutory responsibility within The Housing Scotland Act) who meet with service users on a regular basis to gather their views of the current service provision, and any suggestions of how it can be improved upon. Participation/customer liason officers could focus on the continuing development of opportunities for service users to be involved in the ongoing drive for improvement of the service. The participation strategies used were seen to be effective and it was clear from discussion with service users that they were happy with the service they received. Generally, the people we spoke with were confident they were listened to and any comments or suggestions made would be addressed. page 13 of 34
Staff told us of their open door policy and how service users were encouraged to drop in with concerns, suggestions for improvement, or if they just wanted to chat. We found that Caledonia held regular consultation meetings with service users about forthcoming changes to alleviate any anxieties service users expressed e.g. of how the introduction of Self Directed Support (SDS) would impact on their current service provision. The inspector was welcomed to a service users meeting in a Dundee complex where we had the opportunity to speak with several people informally. The people we spoke with confirmed they have regular access to scheme managers to discuss any matter regarding the care and support they receive. They told us they were happy with the support given, and any issues they may have had, were responded to. They told us they felt safe and secure within the service, knowing there was help there when they needed it and yet at the same time being able to maintain their independence and lifestyle. Service users we spoke with made the following comments:- "I am very happy with care. I feel safe and secure and I regularly take part in chair exercises. We have regular meetings to keep us up to date and we are aware of any changes. Management are approachable and very helpful. I have no concerns. I am not really sure if I have a care plan but if wanted anything I would ask. I have lived here for a number of years and my family comes and visits twice a week, and takes me out shopping. I manage my own money and I like to read a lot. I have no concerns". Service users confirmed they were asked about changes to the services and their ideas of how things could be improved. Individual support plans are in place for all sheltered and very sheltered tenants. Service users were given advance notice of the Caledonia annual customer conference which they could attend. The organisation also put out an annual page 14 of 34
survey, giving service users the opportunity to assess the performance of the service against a number of standard statements. Comments and suggestions made were used to inform a development plan for the service provision. Areas for improvement The provider should continue to build on the opportunities for service users to be involved in assessing and improving all aspects of the service provision. We discussed with the manager how the views of service users could be incorporated in the completion of the self-assessment document that is returned to the Care Inspectorate prior to the inspection visit. We suggested the service should consider taking the views of service users into consideration at supervision and annual appraisals for staff. Grade 4 - Good Number of requirements - 0 Number of recommendations - 0 page 15 of 34
Statement 3 We ensure that service users' health and wellbeing needs are met. Service Strengths We found the service to evidence a good performance in the areas covered by this Quality Statement. We concluded this from speaking with service users and staff; and from sampling personal files. We also took into account the information we received in completed CSQs and some of the comments made in these, by people receiving the service have been recorded within this Quality Statement. The service had made good use of technology to help keep service users safe. In the sheltered housing complexes, motion sensors were in the process of being fitted in the properties. This meant that where no movement had been detected in a person's accommodation while it was known they were at home, the staff would pay them a visit to ensure they had not fallen or become ill. This had been discussed and agreed with the current service users and sensors were only activated where the occupant of the property had agreed to their use. The service also had in place an Adult Support and Protection Policy. Some staff were aware of this policy and what it meant for them in practice. The policy gave guidance for staff of the action they had a responsibility to take if they had any concerns about a service user. We discussed with the registered manager of the service where further guidance and training for staff was needed (See Recommendation 2 under Areas for Improvement). Staff were also supported by volunteers who gave their time to offer friendship to service users, escorting to appointments, and to provide activities for service users to enjoy within and outwith the complex, such as musical entertainment, games and a walking group. page 16 of 34
We sampled four support plans from the Caledonia Support Scheme we visited during this inspection process. We found essential contact information was fully recorded. It was also evident that regular service user updates were sent to Bield Response 24 (BR24) to ensure they always had the most up-to-date information and were fully aware of the person's current status. We continued to find good information about how service users healthcare issues were managed and supported by staff. For example, where service users had issues with mobility we found that a falls risk assessment was in place to help minimise the risk. The level of detail in some of the plans sampled was good. However, not all of the files sampled gave the same level of detail. We found the current system of care planning cumbersome and repetitive and was not always clear. We found that most of the up to date information was detailed in the 'contact sheets' and this information was not always pulled through to the care plan. We found that Support plans contained an 'All About Me' section and we were advised that the manager plans to further develop the information currently recorded to further improve this element of the support plan. We were pleased to hear that the service was currently developing a new person centred, outcome focussed care plan. We look forward to seeing how this develops and this will be reviewed at future inspections (See Recommendation 1 under Areas for Improvement). Plans fully recorded whether the person had opted in or out of daily checks from the manager of the scheme where they reside. These entries were signed and dated by the service user. Generally, only where staff had made contact with a service user in person was the information recorded on the person's contact sheet, whereas telephone contact was recorded separately and did not always record the detail of the contact (See Recommendation 1 Under Areas for Improvement). We reported on at the last inspection where we discussed with the service manager that all professional contact with the service user be recorded in a single identified document. page 17 of 34
This would ensure all staff providing support were aware of all contact made with service users and any issues that had been highlighted. This would also provide a clearer audit trail if ever any information needed to be re-checked. We also noted that the support plans did not always reflect the change to the frequency of contact. We discussed with the manager either a short-term support plan being introduced or updating the existing plan accordingly (See Recommendation 1 Under Areas for Improvement). Areas for improvement At the last inspection we discussed with some scheme staff the inconsistencies in the level of detail recorded in support plans. In some cases this was due to the minimal support needed by the person, and only being able to record the information the person wished to share. However, staff also gave examples of time constraints due to the responsibilities staff had. Staff also reported not receiving training in completion of the new plans. Further detail about this is recorded under Areas for Improvement (See Recommendation 1 in Quality Theme 3, Quality Statement 3. We were advised that the service was currently developing outcome focussed care plans and we look forward to reviewing progress at future inspections. We reported on at the last inspection that there seemed to be a reliance on using contact sheets to document changes rather than updating the appropriate care plan. Where the level of support required by a service user has changed through a change in their health or circumstances, the service should ensure the support plan is updated to reflect this or put in place a short-term support plan where the change is expected to be for a limited period of time only. All professional contact with a service user should be recorded in a single identified document providing a clearer audit trail for all staff. We found at this inspection that a single document was now in place, however, we thought the level of detail we saw could be better and any changes should be made to the care plan. page 18 of 34
Therefore, this recommendation is repeated and will be reviewed at the next inspection (See Recommendation 1). We made a recommendation at the last inspection where we said that although the service was aware of their duty to report concerns about the welfare of a service user to the local authority, there was a lack of clarity for staff of what additional action should be taken if concerns raised are not responded to. The service provider should review their Adult Support and Protection Policy (ASP) to give clearer guidance for staff. As a result of our findings at this inspection we have replaced the recommendation made at the last inspection and made a new recommendation in relation to staff training, in ASP in Quality Statement 3.3 (See Recommendation 2). We suggest that the service develop a protocol for information sharing with other agencies involved in the support of their service users, where there are concerns for their wellbeing and safety. This would ensure that relevant professionals involved in the person's support are alerted to the fact that there are concerns that need addressed. Although we have identified some areas for improvement and made two recommendations of the service, the outcomes for the majority of service users were found to be generally good. Our findings are supported from feedback from service users spoken with in person and from comments made in the Care Inspectorate CSQs. We signposted the service to the Joint Improvement Team publication 'Talking Points Personal Outcomes Approach Practical Guide' for information and guidance. We signposted the care home to The Care Inspectorate and NHS Scotland Publication 'managing falls and fractures in care homes for older people, good practice self-assessment resource' for information and guidance. page 19 of 34
Grade 4 - Good Number of requirements - 0 Recommendations Number of recommendations - 2 1. The provider should ensure that support plans are updated to reflect any changes to a person's health or wellbeing. Where the change is expected to be for a limited period of time only, the provider should give consideration to a short-term support plan being developed and implemented. These support plans should record which other services must be contacted if there is an important change in the services user's health or personal circumstances and when and in what circumstances friends, relatives and carers will be contacted. All professional contact with a service user and the outcome of the visit or telephone conversation, should be fully recorded in a single identified document providing a clearer audit trail for all staff. National Care Standards, Housing Support Services Standard 3.1 : Management and Staffing Arrangements, Standard 4.2: Housing Support Planning. 2. The provider should review and further develop the Adult Support and Protection Policy (ASP) to clarify for staff of which agencies (e.g. social work and the police) must be contacted and in what circumstances. The ASP should include guidance on the additional action to be taken if the reporting of concerns is not responded to. National Care Standards, Housing Support Services - Standard 3.1: Management and Staffing Arrangements; and Standard 4: Housing Support Planning. page 20 of 34
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 Information recorded within Quality Theme 1, Quality Statement 1 is also applicable for this Quality Statement, as participation strategies used to gain the views of service users and carers are the same. Areas for improvement Improvements recorded under Quality Theme 1, Quality Statement 1 are also relevant for this Quality Statement. Grade 4 - Good Number of requirements - 0 Number of recommendations - 0 page 21 of 34
Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service Strengths We found the service to evidence a good performance in the areas covered by this Quality Statement. Supporting evidence was found from sampling staff training records, supervision and appraisal records; minutes of staff meetings; and from speaking with service users and staff. An electronic staff handbook is available to all new employees which details the organisational expectation for all employees. The service has a range of policies which were available on-line which staff can access. Staff indicated that they had received training in the services policies and procedures understood. We were advised that the majority of staff have the necessary qualifications for registration with the Scottish Social Services Council (SSSC), and plans were in place for the remainder of staff to achieve the necessary qualifications. Staff spoken with told us Caledonia was a good organisation to work for, they said they were well supported by their line manager to ensure they were effective in their role. They were able to confirm training opportunities and the support they received through management and regular meetings. Some of the training attended by staff included: Dementia awareness, food hygiene, diabetes, fire warden, health and safety. We found some evidence of some staff having started 'Promoting Excellence', (see details under Areas for Improvement) however it was unclear how may staff were taking part and how the service were promoting and encouraging staff to complete this free training. page 22 of 34
The service users we spoke with were complimentary about the knowledge and the skills of the staff and the support they gave. We received four completed CSQs from staff prior to the inspection. No serious issues were raised in the completed questionnaires, although one indicated that they were not asked their opinion on how the service could improve. One member of staff indicated that we like training in the administration of medication and first aid. We did not receive any comments in the completed CSQs. Areas for improvement We said at the last inspection where we made a recommendation that staff had received no formal training in how to use the new support plan format, but were supplied with an exemplar to follow. This was a single page which covered direct support only. This left the level of detail the organisation expected staff to put into each field open to each staff member's personal interpretation. We have identified for the service manager the files we sampled that we thought recorded good detail, providing the best guidance for staff. We recommend these be used to give training and support to staff in the completion of personal plans. We were advised at this inspection that the service was developing outcome focussed care plans and we suggest that staff will continue to benefit from formal training in their content and completion. Therefore we have decided to repeat this recommendation and we look forward to review progress with the new care plans at future inspections (See Recommendation 1). We found that some staff had completed on-line training on Adult Support and Protection (ASP) However, it was unclear if this training complied with Scottish Legislation and it was unclear if all staff had completed ASP training (See Recommendation 2). We thought it would be helpful if the service had a training matrix detailing the training staff have completed with training plans going forward. page 23 of 34
We also suggest that if would be helpful if staff had an individual training record, individual training plan and individual development plan. We said at the last inspection that the provider should continue to ensure that all staff receive the opportunity for a supervision meeting with their line manager, within specified timescales. These meetings are an important part of ensuring continuing development of staff and ultimately the quality of the service provision. We found at this inspection from the records we saw that supervision and appraisal was not always happening consistently and regularly. We suggest at this inspection that we would like to see a review of the system of supervision and appraisal in line with latest best practice (FCL as detailed below) to ensure it is fit for purpose going forward and supports staff to maintain their registration with SSSC. We signposted the service to the Scottish Social Services Council (SSSC) publication, 'The Framework for Continuous Learning in Social Services' ( FCL ) for information and guidance. We suggest all staff have access to the training available through 'Promoting Excellence' as detailed below. We signposted the service to the The Knowledge Network, Scottish Social Services Council and NHS Education for Scotland for 'Promoting Excellence'- the education framework for all social services staff working with people with dementia for information and guidance www.knowledge.scot.nhs.uk/dementia We signposted the service to the Scottish Social Services Council (SSSC) website for 'Step into leadership' Leadership learning pathways for Scotland's social services for information and guidance. We signposted the service to the Institute for Research and Innovation in Social page 24 of 34
Services (iriss) publication 2015 'achieving effective supervision' for information and guidance. We signposted the service to 'Reflective Writing Guidance notes for students' April 2001 www.shef.ac.uk/uni/projects for information and guidance. We signposted the service to the 'The Improvement Hub' website ( http://ihub.scot/ ) the new improvement resource for health and social care with a suite of programmes and a dedicated team, all in place to support health and social care services to improve for information and guidance. We signposted the service to the Care Inspectorate web site 'The Hub' which provides a 'one-stop-shop' for knowledge, innovation and improvement www.hub.careinspectorate.com We signposted the service to 'Preventing Infection in Care. Infection Prevention and control: Older Person Care Homes and Home Environment DVD and Learning Programme Workbook' Care Inspectorate and NHS Education for Scotland 2011 for information and guidance. We signposted the care home to The Care Inspectorate and NHS Scotland Publication 'managing falls and fractures in care homes for older people, good practice self-assessment resource' for information and guidance. Grade 4 - Good Number of requirements - 0 Recommendations Number of recommendations - 2 1. The provider should ensure that staff are given appropriate training to ensure support plans are sufficiently detailed to allow staff to give the correct level of support to service users. page 25 of 34
National Care Standards, Housing Support Services - Standard 3: Management and Staffing Arrangements. 2. The provider should ensure that all staff have access to relevant and appropriate training in ASP to ensure all staff are fully aware of their responsibilities. (National Care Standards, Housing Support Services - Standard 3: Management and Staffing Arrangements). page 26 of 34
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 Information recorded under Quality Theme 1, Quality Statement 1 and Quality Theme 3, Quality Statement 1 is also relevant for this Quality Statement and has been taken into consideration when awarding the grade. From the self-assessment information we received, the provider informed us that some service users are members of the management committee and also members of the association and attend the Annual General Meetings (AGM). Service users were able to confirm these opportunities for consultation and information sharing about what was happening in the organisation. Comments cards are available in the service for customers to provide feedback and there was also end of tenancy feedback cards. This gave service users the opportunity to tell senior management their thoughts about their experience of the service, and how it could be improved upon for others thinking of coming into the service. Areas for improvement Please see information recorded under Areas for Improvement under Quality Theme 1, Quality Statement 1. page 27 of 34
Grade 4 - Good Number of requirements - 0 Number of recommendations - 0 page 28 of 34
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 We found the service to evidence a good performance for this Quality Statement. We concluded this from speaking with the registered manager of the service, scheme manager, the people who use the service, and staff. Supporting evidence was also gained from looking at quality assurance processes such as audits, staff supervision, minutes of meetings and other participation methods used. We also looked at how the staff team responded to people who used the service. We said at the last inspection where we found a scheme audit system was in place where the line manager would visit one of the schemes annually, to sample records and speak with staff. These audit visits were fully recorded and a copy of the report was sent to the relevant scheme manager for action were required. The process of auditing personal support plans was to ensure they were accurate, up-to-date, signed and dated by all participants, and give sufficient guidance on the level of staff support required. This process was being undertaken during this inspection and will be reviewed at the next inspection. We found at this inspection that the system of audits needed to more thorough and have clearer outcomes from the issues identified. We will continue to review this a future inspections. Monitoring systems were seen to be in place for accidents/incidents and complaints. Records of accidents/incidents and complaints were sent to and audited within the Caledonia head office. Staff performance was monitored through regular discussion with staff, visits to housing schemes and staff meetings. page 29 of 34
The organisation had commissioned an independent survey of service users to evaluate the service provision. Results of the survey were to be used in the development of an improvement plan, to further enhance the services provided by Caledonia. Participants will be informed of outcomes through meetings, the organisation's website and newsletters. Participation strategies used by the service to gain the views of service users, as recorded under Quality Theme 1, Quality Statement 1, were key to quality assurance assessments and the ongoing improvement of the service. In January 2015, Caledonia Housing Support Service was registered in its own right and no longer combined with the Care at Home element of the service. This meant that the size of the service became more manageable for one manager. It should be noted that while the Housing Support Service continues to expand, the organisation may need to look at the management structure, to ensure the good performance identified at this inspection can be maintained and improved further. Service users and staff were kept up-to-date with how the service was performing through monthly, quarterly, and annual performance management reports being published in newsletters for service users, and on the staff intranet. From the management reports we were presented with, we thought that it was not always clear what action the service was taking from the information gathered in the management reports. We would like to see this process being reviewed by the service and improved. We were advised at the last inspection that the service was exploring the learning and development opportunities that could be gained from the complaint process, used by the organisation. They also told us they had considered a formal quality assurance system, such as ISO 9000 (International Organisation for Standardisation for quality assurance systems) for all business functions. It was not clear if any progress had been made with both of these ideas and we will continue to review progress at future inspections. page 30 of 34
We found that the service had a development plan in place for 2016/2017. We found that details on how to make a complaint with the Care Inspectorate was detailed in the 'Tenant Handbook'. Areas for improvement The service should continue to expand on the quality assurance systems used. In addition to the organisational survey, consideration should be given to local surveys being undertaken specific to each complex. Any identified actions needed could then be targeted to the relevant part of the service. We thought the information we saw in completed incident reports could be more detailed and informative. We thought it would have been helpful if the content of incident reports was audited by management to identify gaps in information, and clarify any anomalies and ensure that the information was an accurate record of events. This would also help to inform and improve practice. We were pleased to see that the new manager has started to review and audit accident and incident reports. We will review how this is progressing at future inspections. The registered manager should continue to progress in ensuring all supervisions and audits are completed within specified timescales. A new manager was in post since the last inspection and was found to be enthusiastic and committed to improving and developing the service. We thought it would be helpful if the service had a system to audit informal issues raised by service users, to ensure they were being handled and responded to correctly. Grade 4 - Good Number of requirements - 0 Number of recommendations - 0 page 31 of 34
4 What the service has done to meet any requirements we made at our last inspection Previous requirements There are no outstanding requirements. 5 What the service has done to meet any recommendations we made at our last inspection Previous recommendations There are no outstanding recommendations. 6 Complaints No complaints have been upheld, or partially upheld, since the last inspection. 7 Enforcements We have taken no enforcement action against this care service since the last inspection. page 32 of 34
8 Additional Information There is no additional information. 9 Inspection and grading history Date Type Gradings 24 Mar 2015 Unannounced Care and support 4 - Good Environment Not Assessed Staffing 4 - Good Management and Leadership 4 - Good 28 Nov 2013 Announced (Short Notice) Care and support Environment Staffing Management and Leadership 4 - Good Not Assessed 4 - Good 3 - Adequate page 33 of 34
To find out more This inspection report is published by the Care Inspectorate. You can download this report and others from our website. You can also read more about our work online. Contact Us Care Inspectorate Compass House 11 Riverside Drive Dundee DD1 4NY enquiries@careinspectorate.com 0345 600 9527 www.careinspectorate.com @careinspect Other languages and formats This report is available in other languages and formats on request. Tha am foillseachadh seo ri fhaighinn ann an cruthannan is c?nain eile ma nithear iarrtas. page 34 of 34