Dundas Resource/Day Centre Support Service Without Care at Home Oxgang Road Grangemouth FK3 9EF Telephone:

Dundas Resource/Day Centre Support Service Without Care at Home Oxgang Road Grangemouth FK3 9EF Telephone: 01324 504311 Type of inspection: Unannounced Inspection completed on: 13 June 2014

Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 11 4 Other information 27 5 Summary of grades 28 6 Inspection and grading history 28 Service provided by: Falkirk Council Service provider number: SP2004006884 Care service number: CS2003011564 If you wish to contact the Care Inspectorate about this inspection report, please call us on 0845 600 9527 or email us at enquiries@careinspectorate.com Dundas Resource/Day Centre, page 2 of 30

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 5 Very Good Quality of Environment 6 Excellent Quality of Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well The service provides an individualised activity programme for each person using the service. Staff know each person very well and relationships between staff, people using the service and their carers are very positive. The service uses the facilties available to best advantage to offer a range of activities that meet people's needs and interests. The management team are experienced and committed to providing the best quality of service possible within the resources available. What the service could do better We discussed the use of a personal outcomes approach to planning and reviewing individual's support and the manager agreed to look at options for this. Following changes in the management team, they were getting back on track with regular individual staff supervision. The manager had begun work on developing peer audit arrangements with another manager and planned to continue to develop this. We talked about ways the service could further improve involvement of people using the service and their carers in planning the future development of the service. What the service has done since the last inspection The service had improved how they structured and recorded the consultations with people using the service. We saw this had resulted in people being more involved in planning activities, the changing of room use and upgrading/redecoration needed and in service development in general. They had made a good start to improving carer Dundas Resource/Day Centre, page 3 of 30

involvement with regular open days in the centre. The manager had begun to develop a peer audit process with a manager of another service. Conclusion People using the service are very satisfied with the support provided, the staff providing their support and the management of the service. We heard how they enjoyed coming to the centre, the activities and facilites they could use there, the outings available and the opportunity to meet and socialise with others. They told us about the difference the service made to their physical and emotional wellbeing. Carers also spoke highly of the service, finding the respite it provided invaluable to them and the relationship they had with the person they cared for. Staff were creative and motivated to provide the best quality of support possible. The management team work with people using the service, their carers and the staff team to look at ways the service can continuously improve. Dundas Resource/Day Centre, page 4 of 30

1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Prior to 1 April 2011, this function was carried out by the Care Commission. Information in relation to all care services is available on our website at www.careinspectorate.com. Dundas Resource Centre is a support service which provides active rehabilitation and respite care services to adults who have physical disabilities. The service is provided from a former school within a residential area of Grangemouth adjacent to the local Social Work Services. A variety of facilities are provided within the centre, including a gym, a garden, an arts and crafts area, a computer suite, an adapted kitchen area, a relaxation area and a room for hair and beauty care. The service arranges trips to various local attraction, particularly during the summer. The service also has access to a Disability Living Centre within the same premises. It provides aids and adaptations for people with disabilities to use within their own homes. The service is provided by Falkirk Council and is registered to provide up to 48 places each day. At the time of our inspection around 30 people were using the centre each day, some people attended five days per week and most attended one, two or three days per week depending on their needs. This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April 2011. The philosophy of the service is 'to endeavour to improve the quality of life for people with physical disabilities and their carers' and the 'promotion of independence within individual capabilities'. Requirements and recommendations If we are concerned about some aspect of a service, or think it needs to 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 based on best practice or the National Care Standards. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reform (Scotland) Act 2010 ("the Act") and secondary legislation made under the Act, or a condition of registration. Where there are breaches of Regulations, Orders or conditions, a requirement may be made. Requirements are legally enforceable at the discretion of the Inspectorate. We have not made any requirements or recommendations for improvement in this report. We have agreed areas for continued improvement with the service. Based on the findings of this inspection this service has been awarded the following grades: Dundas Resource/Day Centre, page 5 of 30

Quality of Care and Support - Grade 5 - Very Good Quality of Environment - Grade 6 - Excellent Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 5 - Very 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 0845 600 9527 or visiting one of our offices. Dundas Resource/Day Centre, page 6 of 30

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 an unannounced inspection of the service. A Care Inspectorate inspector carried out the inspection on 12 and 13 July 2014. We gave interim feedback to the manager on 12 July 2014 as they were going on annual leave. As part of the inspection, we took account of the completed annual return and self assessment forms that we asked the provider to submit to us. We sent 30 care standard questionnaires to the manager to distribute to people using the service and their relatives or carers. Twelve people using the service and three relatives returned completed questionnaires. The manager told us she had not been able to distribute all the questionnaires as people had told her they did not want to complete them. We also asked the manager to give out 10 questionnaires to staff and we received nine completed questionnaires. During this inspection we gathered evidence from various sources, including the following: We spoke with * eight people using the service * one relative * the manager * the deputy manager and staff present. We looked at * a sample of records for people using the service * information about the service for people who are using/may want to use the service, including raising a concern/making a complaint. * records of consultation meetings and any actions taken as a result - including consultation with manager and disability information officer * surveys of views gathered by questionnaires e.g. for festive events, summer activities, menus, upgrading the lounge and dining room Dundas Resource/Day Centre, page 7 of 30

* Open Days information * Friends of Dundas information * information on activities available and individual's activity programmes * medication administration and recording systems * environmental and activity risk assessments * records of environmental safety checks, including legionella prevention * fire safety checks * records of repairs/maintenance * records of Health and Safety inspections and audits * sample of staff records, including supervision, performance review and professional development plans * records of staff meetings * staff training information * staff qualifications information * information on "peer" quality audits We saw all the activity areas, toilets and personal care areas in the centre. 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 Dundas Resource/Day Centre, page 8 of 30

What the service has done to meet any recommendations we made at our last inspection 1. The service should further develop their systems for recording consultation and how this has led to improvements in practice. The service had developed proforma questionnaires to use at consultations, recording the feedback and suggestions made by people using the service. We saw how the ideas put forward happened. This recommendation has been met. 2. Managers should involve people who use the service in the development and revision of policies and procedures which govern the operation of the service. The manager had tried to do this but found little interest from people using the service. Many said this was the manager and council's job, not theirs. The manager said if opportunities arose she would consider this again in future. This recommendation has been met. 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 they had completed this with relevant information included for each heading we grade services under. They identified what they thought the service did well, some areas for improvement and any changes they had planned. The provider told us how the people using the service were involved in improving the quality of the service. Dundas Resource/Day Centre, page 9 of 30

Taking the views of people using the care service into account Around 50 people were using the service at the time of our inspection, with around 30 people attending each day. Twelve people using the service returned completed questionnaires to us. They all agreed, 10 of the 12 strongly agreeing, they were happy with the quality of care the service gave them. Comments included, "The centre is well run by an excellent team of staff from the manager down." "I always feel safe here. The staff know that I cannot remember and always take their time to explain things." We spoke to eight people when visiting the centre and three people by phone. They were all very happy with the service, speaking highly of the manager and staff. We heard that the facilities were really useful and that people found it beneficial to be able to meet friends and do things they enjoyed. People told us about the difference the service made, that they felt better physically and emotionally, felt less isolated and found they were able to do things that they hadn't done, sometimes for years. Taking carers' views into account Three relatives returned questionnaires to us. They agreed, two of the three strongly agreeing, they were happy with the quality of care the service gave their family member. Comments included, "This service has had a huge impact on (name's) quality of life and he looks forward to each of his days there. I have personally found it to be a great support to me too - giving me respite from caring and enriching our time together by giving us things/ people to talk about. The staff are most professional and caring and are happy to contact me at home when there is anything I need to know." " All the staff are fantastic, supportive and make (family member) feel very much part of the group. (Family member) loves going to the centre to see (their) many friends." Dundas Resource/Day Centre, page 10 of 30

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: 5 - Very 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 At this inspection we found the service was performing to an excellent standard in relation to this statement. We spoke to some of the people using the service. We saw Falkirk Council's Participation and Engagement strategy and the service's local participation strategy. We looked at individual's records, including support plans and reviews, the service's information brochure and new service user pack, consultation records, minutes of "The Friends of Dundas" meetings and information from open days. We spoke to the manager and staff present. People using the service and, where relevant, their families and others important in their lives were fully involved in planning and reviewing their own support. We heard that people were very involved in deciding what activities they would get involved in. We saw the service had changed areas of the service depending on the interests and abilities of people using the service. The service provided a range of information about the service, including an information brochure for people who might be interested in the service and a new service user information pack, including information on how to complain to the council and to us. We saw that people interested in using the service visited so that they could decide if they wanted to use the centre. The service used consultation events to gather people's feedback on the service and suggestions for improvement. The events were facilitated by the manager and disability information officer, someone familiar to people but external to the service. Events had taken place in May and the main issue raised had been in relation to lunches. The service was completing a survey of views regarding lunches, in order Dundas Resource/Day Centre, page 11 of 30

that they could consider ways to provide a service which would best meet everyone's wishes. The service also had consultations throughout the year, for example to gather suggestions for activities over the festive period or for summer outings. We made a recommendation at our last inspection that the service should develop their systems for recording consultations and how this has led to improvements. The service had developed proforma questionnaires to use at consultations, recording the feedback and suggestions made by people using the service. We saw how the ideas put forward happened. The "Friends of Dundas" committee continued to meet regularly. From speaking to a member and the minutes of meetings it was clear the committee were able to represent the views of people using the service, influence the development of the service and make decisions on how additional funds raised were spent to benefit people using the service. The service had regular open days, when families and others with an interest in the service could visit. They had used a comments book to ask for people's feedback at the last open day. These strengths meant people using the service and their families had a range of ways they could get involved in improving the care the service provided. People we spoke to and their families felt they could make suggestions and raise concerns and the service would listen to them. We saw examples of where the service had made changes based on the feedback from individuals and their families. Areas for improvement We discussed how the service could build on current excellent practice. The Friends of Dundas had taken responsibility for producing a bi-monthly newsletter and we agreed this could include information for people about changes made as a result of their involvement, for example it could include a "You said..., we did..." article. We discussed that using the action plan for improvement included in Falkirk Council's Participation and Engagement strategy with staff and people using the service could generate some new ideas. We suggested that using a more structured approach to getting people's feedback at open days, such as cards asking "what are you most happy with?" and "one thing that would make the service better?", could gather ideas for things to keep doing more of and things to improve on. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Dundas Resource/Day Centre, page 12 of 30

Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths The service met people's health and well-being needs very well. To assess this statement we spoke to some of the people using the service and attended some of the activities. We looked at a sample of individuals' records, including their activity plans, and looked at the facilities available in the centre. We looked at staff's training information. We spoke to the manager and staff present. Each person had a support plan, which included details of their health needs and relevant risk assessments, in place. We saw the support arrangements were reviewed with the person and others significant in their lives at least twice per year and more frequently if changes occurred. The service retained staff well, which meant they knew the individuals using the centre very well, understood their needs and could pick up on changes quickly. Staff were knowledgeable about each person's individual needs. They were proactive in encouraging healthy lifestyles, including diet, exercise and being involved in activities meaningful for the person. Staff met together each morning to discuss the previous day and plan for the day ahead. This meant they were kept fully informed about any changes in individual's health and wellbeing and were prepared for any particular needs for that day. Staff were trained in topics relevant to meeting people's health and wellbeing needs generally, such as food hygiene, infection control and moving and handling. They also received training in meeting specific needs such as peg feeding, emergency medication for managing seizures and stoma care. The service had invited other professionals to deliver workshops for staff on specific conditions people experienced. They had procedures in place to safely administer medication, including regular and as necessary medications. The centre had facilities for staff to be able to carry out individual's personal care safely and respectfully. The building offered opportunities for a range of different activities including a well equipped gym with specialist equipment, a garden space where people were getting involved in growing things and encouraging wildlife, an arts and crafts area, a computer suite, an adapted kitchen area, a relaxation area and a room for hair and beauty care. The service was in the process of developing one room as a games area at the request of people using the service. People using the service had put forward ideas for outings and these were offered on a regular basis, doing things like going out for a pub lunch, going on the barge trip and visiting the safari park. Everyone had an individual activities plan for all the activities they wanted to get involved in. We saw this was reviewed at every review meeting with any requested changes made. We also saw that individuals spoke to their key worker should they want to make Dundas Resource/Day Centre, page 13 of 30

changes between review meetings. The service works with other professionals to meet individual's health and wellbeing needs. We saw the physiotherapist visited regularly to carry out assessments and suggest gym and exercise programmes people could follow. The service had good links with occupational therapists who could assess and offer aids and adaptations to support individual's independent living. The service got support on communication and eating and drinking from the speech and language therapist, advice on special dietary requirements by the dietician and continence advice from the continence nurse. A disability information officer was based in the same building as the centre uses. We heard this meant she was easily accessible for advice, particularly on financial matters. People could also access information about short breaks easily. These strengths meant people using the service and their families could be reassured the service was working hard to make sure they stayed as healthy and well as they could. We found many examples from talking to people and their families and in individual's records of how people were being supported with healthy, active lifestyles and with accessing health services. People who returned questionnaires to us agreed, 12 of the 15 strongly agreeing, they were happy with the quality of care they got from the service. People we met during our inspection told us they enjoyed coming to the centre and the range of activities they got involved in. Family members told us the respite the service offered them was invaluable. We heard about things people were achieving as a result of using the service, such as maintaining and regaining skills and independence and improving confidence and self-esteem. A number of people told us they had felt very isolated and depressed prior to using the service and the social contact and having something to look forward to had made a real difference to their lives. Areas for improvement We discussed that the use of a personal outcomes approach could further improve how the service meets people's health and wellbeing needs. This could help develop more personalised services for each person and help identify other information and services that could have a positive impact on their quality of life. The manager agreed to look at the Talking Points personal outcomes approach and the Outcomes Star for people with long-term conditions to consider how appropriate they would be and to talk to other day service managers to share ideas. Each person has a formal annual review. We discussed the format for recording interim reviews and the manager will consider adapting a "detailed contact record". In accordance with Falkirk council's policy, people "retire" from using the centre at age 65. We heard this is a difficult time for people as they have well established relationships and enjoy the activities. They can struggle to find other services that will meet their needs. Some people can feel that day services for older people are not suitable for them. The service works hard to manage this sensitively and support Dundas Resource/Day Centre, page 14 of 30

people to identify other appropriate services, taking time with people to make changes. However people can feel anxious and concerned that they will become socially isolated. Falkirk council could look at how this transition period could be supported to make sure people and their families (carers) continue to have support that is appropriate to their age, interests and needs. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Dundas Resource/Day Centre, page 15 of 30

Quality Theme 2: Quality of Environment Grade awarded for this theme: 6 - Excellent Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths The service was excellent at involving people they support and their families in improving the quality of the environment. The evidence we looked at for Quality Theme 1 Statement 1 was also relevant for this statement. The strengths noted under Quality Theme 1 Statement 1 are also relevant to this statement. The service revamped and changed use for areas in the centre as people's needs and interests changed. For example an area which had been used for woodwork was underused and it was agreed to refurbish this as an area for hair and beauty care. The service had consulted people using the service when redecorating/refurbishing any area of the service, including the dining room and the relaxation room and the room used for hair and beauty care. People were being asked what they would like to see in the games room which was in the process of being refurbished. People were actively involved in gardening, creating a relaxing and productive outside space. The "Friends of Dundas" had been actively involved in fund-raising and deciding what to spend funds on for the benefit of people using the service. Additional equipment for the gym, computer suite, kitchen and garden had been purchased as a result. These strengths meant people using the service and their families had a range of ways they could get involved in improving the environment the service operated in. Areas for improvement As noted under Quality Theme 1 Statement 1 we discussed ideas on how the service could build on current excellent practice. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Dundas Resource/Day Centre, page 16 of 30

Statement 2 We make sure that the environment is safe and service users are protected. Service strengths We found the service to be excellent at making sure the environment was safe for the people living there. Some of the information we looked at to assess Quality Theme 1 Statement 3 was also relevant to this statement. We looked around the centre and looked at records of health and safety checks and equipment maintenance. We spoke to the manager about health and safety management. The strengths noted under Quality Theme 1 Statement 3 in relation to individual's risk assessments, safe medication administration procedures and staff training are also relevant to this statement. Each person had an evacuation plan in place, detailing the support they would need to leave the building in the event of fire. Falkirk council had safe recruitment procedures in place, including checks to make sure staff are safe to work with vulnerable adults. They also have adult support and protection procedures in place and staff had opportunities to refresh their knowledge in these procedures. The building is accessible. It is spacious to allow individuals with mobility issues to move around safely and has well equipped personal care areas, including tracking hoist equipment to enable personal care to be carried out safely. The service had generic risk assessments in place covering all areas of the building, staff's practice and for one-off events. These were reviewed at least annually and more regularly if necessary. The service carried out regular fire safety checks and evacuation practice. They had systems in place to regularly check equipment, with maintenance contracts in place for specialist equipment. Regular legionella checks were carried out. We saw the service had systems in place for reporting and following up any repairs. The centre was cleaned regularly and was free from any obvious hazards. The manager told us this was something staff were very aware of given the needs of people using the service. We saw that the council's health and safety officer carried out an annual audit of the procedures in place. We saw the most recent audit which showed the service was managing health and safety issues well. A few maintenance issues were being followed up by the manager with the council's maintenance section. These strengths meant that people using the service and their families could feel reassured that the service was working hard to make sure the environment was free from hazards and they were kept safe. Dundas Resource/Day Centre, page 17 of 30

Areas for improvement The service intends to maintain and build on excellent practice, maintaining all safety checks and making sure any repairs or improvements are carried out in good time. The maintenance issues noted in the health and safety audit had been outstanding since the audit, although the manager re-assured us that she had been following these up. The service could look at agreeing timescales for completion of non-urgent repairs with the maintenance section and reporting to the health and safety officer where timescales were not being met. The manager intends that two staff will complete "Cleanliness Champion" training to be better able to audit the cleanliness of the environment, further minimising infection risks. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Dundas Resource/Day Centre, page 18 of 30

Quality Theme 3: Quality of Staffing Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths The service was very good at involving people who use the service and their families in improving the quality of staffing in the service. The evidence we looked at for Quality Theme 1 Statement 1 was also relevant for this statement. The strengths noted under Quality Theme 1 Statement 1 are also relevant to this statement. People using the service had been involved in selecting new staff, deciding on questions they wanted to ask candidates and interviewing them with support from the disability information officer. We heard from a newer member of staff that the interview with people using the service had been the most challenging part of the process. The service's training programme had been structured based on the needs and issues people using the service commonly experience. Staff had learning opportunities relevant to particular needs of individuals they support. These strengths meant people using the service and their families had a range of ways they could get involved in improving staffing in the service. Areas for improvement The areas for improvement noted under Quality Theme 1 Statement 1 are also relevant to this statement. The manager agreed they could involve people more in staff's performance review by asking individuals for feedback about their key worker's performance. This could be done by asking a few key questions and the information gathered could be included in a 360 degree performance appraisal. Falkirk council and the service could consider how people using the service could be involved in delivering staff's training, including induction training for new staff. Dundas Resource/Day Centre, page 19 of 30

Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Dundas Resource/Day Centre, page 20 of 30

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's performance to be very good in making sure people received support from staff who had the skills, knowledge and experience required. To assess this we took into account the views of people using the service and their families. We looked at a sample of staff records, training records, information on staff qualifications and some staff meeting records. We also looked at questionnaires staff returned to us and spoke to the manager and staff present. We saw staff work with people. We found the service had effective system in place to support staff's professional development, including regular 1:1 supervision meetings, annual performance review and professional development. The service had staff meetings every morning, where staff were kept informed about service developments and shared information and practice. As noted under Quality Theme 1 Statement 3 staff had learning and development opportunities relevant to meeting the needs of the people using the service. Most of the staff team had qualifications that were relevant for their role and the service aimed to support staff to achieve qualifications that would support their career development. The manager was registered with the Scottish Social Services Council. Most staff who returned questionnaires to us said they had regular 1:1 supervision and all said they had opportunities to meet up with colleagues. They said they had the skills and knowledge to support people using the service and did not have any training needs that were not being met by the service. Staff we met were very positive about their role, felt motivated and said they worked well as a team. We saw them work skilfully and respectfully with the people they support. We saw that questionnaires returned from professional partners included very positive comments about staff's knowledge and understanding of individual's support needs. These strengths meant that people using the service and their families could be reassured that the service worked hard to make sure staff delivering their support were safe and competent to do so. People the service supports and relatives who returned questionnaires to us agreed, 12 of the 15 strongly agreeing, that staff had the skills to support them. They agreed, 13 of the 15 strongly agreeing, that staff treated them with respect. People we met during our inspection spoke highly of the staff and it was clear there were very positive relationships between people using the service and the staff supporting them. Dundas Resource/Day Centre, page 21 of 30

Areas for improvement The service acknowledged that changes in the senior staff team had resulted in 1:1 supervision meetings being less regular. The changes had taken place and the deputy managers now had plans in place to hold regular 1:1 supervision meetings with all staff. The manager was completing performance reviews with staff and would agree professional development plans with each member of staff. The service plans to make sure all staff have opportunities to achieve a qualification relevant to their role. They will continue to develop learning opportunities for staff relevant to the needs of people using the service, including inviting speakers to staff meetings on topics such as tissue viability, infection control, diabetes and multiple sclerosis. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Dundas Resource/Day Centre, page 22 of 30

Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 5 - Very 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 The service was very good at involving people who use the service and their families in improving the quality of management and leadership in the service. The evidence we looked at for Quality Theme 1, 2 and 3 Statement 1 was also relevant for this statement. The strengths noted under Quality Theme 1, 2 and 3 Statement 1 are also relevant to this statement. The manager and deputy managers were very involved in the day-to-day activities of the centre. They were available to discuss any suggestions or concerns with people using the service or their families. The manager met with the "Friends of Dundas" so they could discuss any ideas or issues directly with her. The involvement of the disability information officer in the service meant people had an opportunity to discuss any concerns about the management of the service with someone external to the service. We made a recommendation that managers should involve people who use the service in the development and revision of policies and procedures. The manager had tried to do this but found little interest from people using the service. Many said this was the manager and council's job, not theirs. The manager said if opportunities arose she would consider this again in future. These strengths meant people the service supports and their families had a range of ways they could get involved in improving the management and leadership in the service. Areas for improvement The areas for improvement noted under Quality Theme 1, 2 and 3 Statement 1 are also relevant to this statement. We discussed that the service could consider holding a planning event involving Dundas Resource/Day Centre, page 23 of 30

people using the centre, their families and carers and staff. We suggested they could use ways for people to put forward their vision of a "dream" day service, which they could then review and decide what would be possible and plan towards this. We agreed people may find this more meaningful than being involved in reviewing and developing policy and procedures. The service could develop opportunities for people using the service and their families to contribute to managers' performance review and in the selection of new managers. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Dundas Resource/Day Centre, page 24 of 30

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 At this inspection we found the performance of the service was very good for this statement. The information we looked at to assess the quality of care and support, the quality of environment and the quality of staffing was relevant to this statement. We looked at work the manager had been involved in developing peer audit and spoke to the manager about quality assurance. The strengths relating to service user participation noted under Quality Theme 1, 2, 3 and 4 Statement 1 are relevant to this statement. These provide opportunities for people the service supports and their families to influence the quality of service they receive. participation was a priority focus for the service in assessing and improving the quality of the service. The strengths noted under Quality Theme 2 Statement 2 in relation to having a safe environment are relevant to this statement. These strengths meant people using the service and their families could feel reassured that the service was working hard to make sure the environment was free from hazards and they were kept safe. The strengths noted under Quality Theme 3 Statement 3 in relation to having a professional, trained and motivated workforce contribute to assuring the quality of the service people receive, providing reassurance that staff who are delivering their support are safe and competent to do so. The service had asked for feedback from other professionals with an interest in the service using questionnaires. Feedback received had been very positive and the service was working to improve the response rate. The manager had been working with a manager in another service to develop an audit tool they could use to audit each other's service. They had developed a tool for auditing records for people using the service and had begun the process of peer audit. They have found the process useful in sharing practice and learning from each other. The service works well with us in our role as regulator. They provide us with the information we require and notify us about any events they must tell us about. They had worked to make the improvements we agreed and recommended at our last inspection. They made sure we had access to the information we needed and encouraged people using the service and staff to take part in the inspection. These quality assurance systems and processes meant people using the service and Dundas Resource/Day Centre, page 25 of 30

their families could feel the service is working hard to make sure their service continues to improve. Areas for improvement The areas for improvement relating to service user participation noted under Quality Theme 1, 2, 3 and 4 Statement 1 are relevant to this statement, increasing opportunities for people using the service and their families to influence the quality of service they receive. The areas for improvement noted under Quality Theme 2 Statement 2 in relation to having a safe environment will reassure people the service is continuing to work hard to make sure they are kept safe. The areas for improvement noted under Quality Theme 3 Statement 3 in relation to having a professional, trained and motivated workforce will contribute to continuing to improve the quality of the service, reassuring people that the service is continuing to improve how they support staff's professional development. The manager plans to continue to develop the peer audit process. Once the service user records audit is established they plan to work on a format for auditing other aspects of the service relevant to quality. We suggested that the European Framework for Quality Management might be useful with developing this. We discussed that the introduction of a personal outcomes approach (see Quality Theme 1 Statement 3) could provide the service with a tool to help monitor the impact the service has on the quality of people's lives and generate ideas for continuous improvement. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Dundas Resource/Day Centre, page 26 of 30

4 Other information Complaints No complaints have been upheld, or partially upheld, since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in 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). Dundas Resource/Day Centre, page 27 of 30

5 Summary of grades Quality of Care and Support - 5 - Very Good Statement 1 Statement 3 6 - Excellent 5 - Very Good Quality of Environment - 6 - Excellent Statement 1 Statement 2 6 - Excellent 6 - Excellent Quality of Staffing - 5 - Very Good Statement 1 Statement 3 5 - Very Good 5 - Very Good Quality of Management and Leadership - 5 - Very Good Statement 1 Statement 4 5 - Very Good 5 - Very Good 6 Inspection and grading history Date Type Gradings 12 Jan 2012 Announced (Short Notice) Care and support Environment Staffing Management and Leadership 5 - Very Good Not Assessed Not Assessed 5 - Very Good 17 Nov 2010 Announced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed 4 Feb 2010 Announced Care and support 5 - Very Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed Dundas Resource/Day Centre, page 28 of 30

26 Jun 2008 Announced Care and support 5 - Very Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Dundas Resource/Day Centre, page 29 of 30

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 Dundas Resource/Day Centre, page 30 of 30