Sheltered Housing - Cumbernauld/ Kilsyth Housing Support Service Kilsyth FSS Parkfoot Street Kilsyth Glasgow G65 9AA Telephone: 01236 828101 Inspected by: Linda Taylor Type of inspection: Announced (Short Notice) Inspection completed on: 23 July 2013
Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 6 3 The inspection 9 4 Other information 19 5 Summary of grades 20 6 Inspection and grading history 20 Service provided by: North Lanarkshire Council Service provider number: SP2003000237 Care service number: CS2004069095 Contact details for the inspector who inspected this service: Linda Taylor Telephone 01786 432940 Email enquiries@careinspectorate.com Sheltered Housing - Cumbernauld/Kilsyth, page 2 of 21
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 3 Adequate Quality of Management and Leadership 3 Adequate What the service does well The service was very good at ensuring tenants health and wellbeing needs were met. There was a range of interesting and varied activities for people to take part in. Tenants spoke highly of the staff and told us that they thought the staff were very good at supporting them. What the service could do better The service should look at ways to improve meaningful participation with tenants in order that regular feedback about the quality of the service can be obtained. This would allow tenants feedback to directly influence the services continuous improvement plans. Better monitoring of certain core aspects of the service should be undertaken. For example, by introducing regular and ongoing monitoring of the details contained in tenants support plans. What the service has done since the last inspection There were no recommendations or requirements from the last inspection. Some areas for improvement had been maintained for example; continuing to meet tenants health and well-being needs. Some of the areas for improvement had not been progressed, they have been repeated in this report for example; how tenants comments could improve staffing and the quality of management and leadership. These are discussed under areas for improvement under quality statement 3.1,4.1 and 4.4. Sheltered Housing - Cumbernauld/Kilsyth, page 3 of 21
Conclusion Overall the service provided very good support to tenants and ensured they felt safe and secure. Some work was needed to improve meaningful participation with tenants so that their views are obtained to improve and develop the quality of the service. Who did this inspection Linda Taylor Sheltered Housing - Cumbernauld/Kilsyth, page 4 of 21
1 About the service we inspected Cumbernauld and Kilsyth sheltered housing service is provided by North Lanarkshire Council, and is registered as a housing support service. The service is provided to cover seven complexes. The aims of the service are " To provide a high quality housing support service to older people, which enables supports, and encourages them to live independently by Providing a range of housing support services tailored to meet individual needs Providing a service where dignity and privacy of all tenants is paramount Promoting social inclusion Ensuring that all tenants are kept informed, and have access to information in respect of their rights and choices". 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 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. 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 0845 600 9527 or visiting one of our offices. Sheltered Housing - Cumbernauld/Kilsyth, page 5 of 21
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 after a short announced inspection on the 12th June 2013, when we visited the office premises to look at records and spoke with the service manager and the sheltered housing development officer. We also visited Larch Grove complex. The inspection took place between 10am and 4.15pm. A further arranged visit took place on the 12th July 2013 to meet tenants and staff at Pirnie Place and Rannoch Court. The inspection took place between 11am and 3.30pm. Feedback was given to the area housing officer, the service manager and the sheltered housing development officer on the 23rd July 2013 between 2pm and 3.30pm. The inspection was carried out by Care Inspectorate inspector Linda Taylor. As part of the inspection, we took account of the completed annual return forms that we asked the provider to complete and submit to us. We sent 90 care standards questionnaires to the service manager to distribute to the tenants. 16 tenants sent us completed questionnaires. We also asked the service manager to hand out 10 care standard questionnaires to staff and we received six completed questionnaires. During this inspection process, we gathered evidence from various sources, including the following: We spoke with: * nine tenants * the area housing manager * the service manager * the sheltered housing development officer * three members of staff We looked at: * policies and procedures Sheltered Housing - Cumbernauld/Kilsyth, page 6 of 21
* information packs * a sample of feedback forms from the annual event * complaints * minutes of staff meetings * health and safety audit * training records * supervision records * induction records * a sample of support plans and reviews * certificate of registration * accidents/incidents * newsletters * maintenance records 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 Sheltered Housing - Cumbernauld/Kilsyth, page 7 of 21
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 did not receive a self assessment from the provider. Taking the views of people using the care service into account For this inspection we received views from 26 out of the 251 tenants who use the service. 16 people gave their views via the care standards questionnaires and we spoke to a further 9 people in three small discussion groups. People spoke very highly about the staff who supported them and thought the service was very good. All the views expressed were very positive. Six people who responded to our questionnaire said they were not aware of their support plan and three people were not aware of the complaints procedure. We asked staff to remind tenants about these. We have included further comments throughout the report. Taking carers' views into account We did not speak with any relatives or carers for this inspection. Sheltered Housing - Cumbernauld/Kilsyth, page 8 of 21
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 We found the service to be good at involving tenants. We concluded this from speaking to tenants, from the results of our questionnaires, from speaking to staff and looking at support plans. Tenants told us that they were consulted about events, activities that took place and that they had a choice if they wanted to participate or not. We saw good examples of how people's interests were supported for example with arts and crafts, gardening projects. We saw examples of newsletters which informed tenants of up and coming events, there were comments slips attached that tenants could complete. The services we visited had suggestion boxes in place so that tenants could post suggestions or comments. Staff told us that they had contact with tenants on a daily basis and that any need for support was acted upon. For example; staff told us how they supported tenants to make appointments with their GP. It was very good to see in one complex that an activity committee had been started with tenants taking the role of chair, treasurer etc. The committee took forward ideas and raised funds. We saw by looking at the support plans that tenants were involved from the start of their tenancy in the support they required. We found that reviews took place every six months and that tenants were consulted about any changes. The support plans and Sheltered Housing - Cumbernauld/Kilsyth, page 9 of 21
reviews were signed by the tenants. This ensures that tenants are involved in the support they need and that the support given is up to date. Areas for improvement We found that tenants did not make much use of the feedback systems in place and we asked the manager to explore other methods to encourage and obtain more meaningful feedback from tenants. This might be by asking tenants to comment about the service at their review or adding more detail to the newsletter about how tenants suggestions and comments were acted upon (see recommendation 1). Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service should explore other methods of obtaining tenants comments and suggestions and evidence how the suggestions and comments made have been actioned. National care standards-housing support services Standard 3 - management and staffing Sheltered Housing - Cumbernauld/Kilsyth, page 10 of 21
Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths We found the service to be very good at promoting tenants heath and wellbeing. We spoke with tenants and staff and looked at support plans to help us decide on the grade to be awarded. Tenants thought the care and support they received was very good, some tenants commented " its very good here" "marvelous" " brilliant". We saw very good examples of how the service had enabled and improved tenants wellbeing. For example in one complex a gardening project had been introduced and this had encouraged some tenants to become involved. We found from speaking to tenants that the project had had positive outcomes for people, as it had encouraged people to be more active and had improved the garden area with lots of flowers being planted to give more colour and brightness to the area. Tenants were very proud of the gardens. We saw in another complex that staff had worked hard to introduce a wide range of arts and crafts for example, glass making, silk painting, making greeting cards. Tenants told us how much they enjoyed the arts and crafts and also the social part of meeting up with other tenants. It was good to see that other people from the community joined in some of the activities enabling tenants to keep in touch with local people. There was a range of activities for tenants to take part in. Of the complexes we visited all three had designated rooms/hall that could be used for activities such as chair yoga, bingo, and a book club. Staff helped to organise outings and trips for example to lunch clubs, Dobbies garden centre, Ayr. Visits were being planned for an outing to Callender and some shows. Tenants told us that there was entertainment provided and that different events were celebrated such as special birthdays and St Patrick's day. Tenants were very happy with the activities and outings provided. We felt there was a very good choice of activities for tenants to take part in which would help to improve and maintain their wellbeing. We looked at five support plans from the three complexes we visited. We saw that the majority of tenants required minimal support. We saw that staff were very good at offering support and that changes were documented at reviews held and in the case notes. Staff discussed with us examples of the support they gave, such as contacting social workers, GPs, and relatives were appropriate to highlight any issues of concern, and other types of support for example; ensuring repairs are reported quickly and dealt with, giving extra support to tenants who were new. Sheltered Housing - Cumbernauld/Kilsyth, page 11 of 21
Tenants told us that the out of hours system worked very well with staff responding very quickly. Tenants told us that they felt safe and secure at the complex with very good support from staff. The sheltered housing development officer told us of the good links with the NHS and other professionals through the Local Planning Group to discuss specific needs of older people and how best to meet the needs. Staff told us that they carry out regular maintenance checks such as checks on alarm systems and we saw that these were recorded. Areas for improvement The sheltered housing development officer informed us that accidents and incidents or any concerns were emailed to her directly by staff. We were satisfied that systems were in place. The area housing officer informed us that audits were completed on accidents and incidents. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Sheltered Housing - Cumbernauld/Kilsyth, page 12 of 21
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 We concluded that the service had adequate systems in place to involve tenants to make suggestions or comments. We decided this from speaking to tenants and reviewing newsletters. The information in quality statement 1.1 is also relevant to this statement Tenants thought the staff were very good, comments made were that staff "bend over backwards for you" and " we have two great carers here" "don't know what I would have done without them". The newsletters had a section at the back that tenants could use for any comments and suggestions. Areas for improvement At the last inspection we asked the service to show how the quality of staffing had improved as a result of tenants participation. We did not see any evidence that tenants were asked specifically about staff. We have made a recommendation about this under quality statement 4.4. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Sheltered Housing - Cumbernauld/Kilsyth, page 13 of 21
Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths We graded the service as adequate for this quality statement after we looked at staff registered with the Scottish Social Service Council (SSSC) (which is the professional body for all social care staff and looks at training and competencies of staff registered), staff training, supervision notes, induction files and minutes of staff meetings. The staff training matrix recorded 15 staff having received training. Two new staff were to be added. Topics covered included, dementia, fire, bogus callers, first aid. Staff told us that their training needs had been met. The area housing manager told us that a training matrix had been completed for staff. This should ensure that all staff's training needs are met and tenants received support from skilled and competent staff. The service manager told us that staff receive a corporate induction along with an induction for the specific role and that new staff shadow the sheltered housing officer for two days. We looked at induction files for two new staff members and found that a basic induction had been done and was signed and dated. The sheltered housing development officer told us that in each complex an information folder was available for staff. We felt the 'House keeping book' contained very good information on "what to do if"...particulalry for new staff to help them become more orientated to the service. We looked at supervision files and found that supervision occurs every six months. Relevant areas were discussed such as tenants, time keeping, sickness, training needs. We saw that staff had requested training and this had been actioned. Staff told us that they got very good support from managers. Staff meetings took place regularly and had a good attendance. There was good information shared with staff to keep them informed such as organisational changes, updates on policies and procedures. It was good to see that actions identified had been followed up and that staff were kept informed. We did not look at recruitment files as these were held out with the service. Areas for improvement The new manager was not aware that they must be registered with the SSSC. We advised the manager to make contact with the SSSC as a matter of urgency. The service should ensure that all staff who need to be registered make application. Management must be aware of their obligations to register staff with the professional body for social care. Sheltered Housing - Cumbernauld/Kilsyth, page 14 of 21
We noted that not all staff had up to date training on adult support and protection. We were informed that training was scheduled to take place and staff confirmed that training had been scheduled for them. The service should ensure that all staff receive training on adult support and protection on a regular basis. We saw that staff supervision sessions took place every six months although one staff member said it was under a year ago and another indicated in the questionnaire that supervision was not applicable. New staff should be given more frequent support initially to ensure they are fully supported in their new role and this should be recorded. The recording of the supervision sessions could be more detailed. Not all staff were aware of the national care standards or the SSSC. These are topics that could be discussed at staff meetings. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Sheltered Housing - Cumbernauld/Kilsyth, page 15 of 21
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 We graded the service as adequate for this statement after speaking to tenants. The information in quality statement 1.1 is also relevant to this statement. Tenants told us that they were very satisfied with the quality of the service and the managers. Areas for improvement At the last inspection we asked the service to show how the quality of management and leadership had improved as a result of tenants involvement. We did not see any evidence that tenants were asked specifically about the quality of management and leadership. We made a recommendation about this under quality statement 4.4. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Sheltered Housing - Cumbernauld/Kilsyth, page 16 of 21
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 The sheltered housing development officer informed us that the service holds an annual event for tenants with specific speakers such as someone to inform tenants about benefits, heating and we saw that tenants had found the events useful. Tenants can comment on the event by completing a short feedback sheet and we saw that positive comments had been made. The sheltered housing development officer told us that the feedback sheets gave tenants opportunity to comment on the service. The area housing manager told us that North Lanarkshire Council (NLC) send out questionnaires to tenants every two years and was due to take place. Staff told us that they were sent questionnaires and feedback was given to them. We saw that health and safety audits were carried out by NLC and that prompt action was taken by the service to remedy any faults. Areas for improvement The service manager and the sheltered housing development officer were not aware that they had to notify the care inspectorate about any incidents. The legislation requires services to notify us without delay (see requirement 1). The service manager was signposted to the guidance on notifications. During this inspection we discussed with the line manager and in turn the external line manager that the service was operating outwith their conditions of registration. The service was being provided from 8 premises and it was only registered for 7. It was established that this had been an oversight by the management team. An application to vary the registration has now been received. We did not see any evidence of how tenants had been asked to be involved in making specific comment about the quality of the service, for example; looking at the quality statements for inspection and asking for views on care and support, quality of staffing, and the quality of management and leadership. We suggested to the management team that these areas should be covered when tenants are asked for feedback about the service (see recommendation 1). We discussed with the management team the use of quality monitoring specific to the sheltered housing complex to improve the quality of the service, for example; monitoring support plans, review meetings, staff supervision. We suggested that they consider using audit tools to monitor documentation (see recommendation 2). The sheltered housing development officer discussed using supervision sessions as a means to monitor the support plans. We will monitor progress on this at the next inspection. Sheltered Housing - Cumbernauld/Kilsyth, page 17 of 21
Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 2 Requirements 1. The care Inspectorate must be notified of any serious incident that might have serious implications on the health and wellbeing of service users. This is in oder to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210, regulation 4. Timescale for meeting this requirement: on receipt of this report Recommendations 1. The service should consider asking specific questions to tenants about the quality of the service provided, for example quality of care and support, quality of staffing and the quality of management and leadership. National care standards-housing support services Standard 3 - management and staffing 2. The service should consider introducing quality monitoring for some aspects of the service to ensure a good quality service is provided National care standards-housing support services Standard 3 - management and staffing Sheltered Housing - Cumbernauld/Kilsyth, page 18 of 21
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 We found when we carried out the inspection that one of the complexes was not registered with us. We asked the manager to complete a variation form (see quality statement 4.4). 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). Sheltered Housing - Cumbernauld/Kilsyth, page 19 of 21
5 Summary of grades Quality of Care and Support - 4 - Good Statement 1 Statement 3 4 - Good 5 - Very Good 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 10 Aug 2010 Announced Care and support 5 - Very Good Staffing 4 - Good Management and Leadership 4 - Good 11 Sep 2009 Announced Care and support 4 - Good Staffing 3 - Adequate Management and Leadership 3 - Adequate 14 Aug 2008 Announced Care and support 4 - Good 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. Sheltered Housing - Cumbernauld/Kilsyth, page 20 of 21
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 0845 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 0845 600 9527. Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: 0845 600 9527 Email: enquiries@careinspectorate.com Web: www.careinspectorate.com Sheltered Housing - Cumbernauld/Kilsyth, page 21 of 21