Drylaw Rainbow Club Day Centre Support Service Without Care at Home Drylaw Parish Church Groathill Road North Edinburgh EH4 2RG Type of inspection: Unannounced Inspection completed on: 15 December 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 23 5 Summary of grades 24 6 Inspection and grading history 24 Service provided by: Drylaw Rainbow Club Day Centre Service provider number: SP2007009026 Care service number: CS2008180109 If you wish to contact the Care Inspectorate about this inspection report, please call us on 0345 600 9527 or email us at enquiries@careinspectorate.com Drylaw Rainbow Club Day Centre, page 2 of 25
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 5 Very Good Quality of Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well The service is a valuable resource and actively involves volunteers from the local community. There are good systems in place to assess and review people who use the service. The staff team are committed and take a pride in the work they do. What the service could do better We assessed that the service should continue to maintain the standard they have achieved. The noticeboard at the entrance should be review from time to time to make sure that all information is up to date. The manager planned to reinforce the complaint procedure in the service. What the service has done since the last inspection The service had taken action to meet 4 recommendations made at the last inspection. Details can be seen in Care and support, statements 1 and 5 of this report. There had been a review of staffing in the service and a new deputy manager had been appointed and the manager had achieved management qualifications. The manager was stimulated to implement her learning into practice. Drylaw Rainbow Club Day Centre, page 3 of 25
Conclusion Drylaw Rainbow Club Day Centre was a well-managed and organised service. It was set in the heart of the community and encouraged involvement of locals. Service users and relatives/carers who responded through questionnaires or during the inspection praised the staff and told us about how the service was an important part of their life.it had a group of staff and volunteers who worked well as a team to ensure that the experience of day care was positive for people who used the service and their families. Drylaw Rainbow Club Day Centre, page 4 of 25
1 About the service we inspected Drylaw Rainbow Club Service (referred to as "the service" in the report), is managed by a voluntary management committee and was registered with the Care inspectorate on 1 April 2011. The Care Inspectorate regulates care services in Scotland. It awards grades for services based on findings of inspections. These grades, including any that services were previously awarded by the Care Commission, are available on www.careinspectorate.com Before April 2011 this service was registered with the Care Commission. On this date the new scrutiny body, Social Care and Social Work Improvement Scotland (SCSWIS) took over the work of the Care Commission, including the registration of care services. This means that from 1 April 2011 this service continued its registration under the new body SCSWIS now the Care Inspectorate. Drylaw Rainbow Club Day Care Service is a community based support service for older people. The service is a charity and is run by a Manager and team of four Social Care Workers. The Manager reports regularly to the services Management Committee. The support service was registered to provide care and support to up to 15 service users each day. The service operates from a hall in Drylaw Parish Church. There was access to toilet and kitchen facilities and a separate office area. The service is open between 8:30am and 5pm Monday to Friday. Service users attend on specified days agreed in advance at the time of accepting a referral. Transport is also provided where needed. The aims and objectives of the service included promoting social inclusion and having costs of the service in a fair way which does not disadvantage those on lower incomes. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 5 - Very Good Quality of Environment - Grade 5 - Very Good Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 5 - Very Good Drylaw Rainbow Club Day Centre, page 5 of 25
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. Drylaw Rainbow Club Day Centre, page 6 of 25
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 compiled the report following an unannounced inspection. The inspection was carried out by one inspector from the Care Inspectorate which took place on 15 December 2014 between 10:30am and 13:00 pm approximately. As requested by us, the manager sent us an annual return and a self assessment prior to the inspection. In this inspection we gathered evidence from various sources, including : The Certificate of Registration. Insurance certificate. The satisfaction survey completed by the service in October 2014. Information in the annual return. Evidence from the self assessment. Policy and procedure information. The service 'welcome pack'. Two care and support plans and associated documentation. The service correspondence file (copies of letters and information on planned events to service users, relatives/carers and unsolicited letters of thanks received by the service). As part of the inspection we also sent out thirty pre inspection questionnaires, eighteen of which were returned to us, prior to the inspection visit. We took the comments from these into account to make an assessment of how the service operated. We spoke with: Service users attending the day centre. The manager. The deputy manager. Staff working in the service, including three volunteers and two family members. We observed how staff worked and interacted with people using the service. Drylaw Rainbow Club Day Centre, page 7 of 25
During the inspection we looked at the areas where the service was delivered and the facilities available. 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 Drylaw Rainbow Club Day Centre, page 8 of 25
What the service has done to meet any recommendations we made at our last inspection Four recommendations were made at the last inspection completed on 18 October 2011. Progress on four recommendations can be seen in Quality of care and support statements 1 and 3 of this report. 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. This was completed and returned as requested. Taking the views of people using the care service into account Eighteen of thirty pre inspection questionnaires sent were returned prior to the inspection. Some of these had been completed on behalf of their relative who attended the day club. All of the returned questionnaires confirmed that service users strongly agreed or agreed that overall they were happy with the quality of the care from this service. Some of the comments from service users were as follows: "I go to the Rainbow Club and it really helps my family to know that I am taken care of when there, also transport comes for me and the staff are very helpful and treat me with respect". "Feel that staff are competent and meet my needs" and "I enjoy my visits once a week". People we spoke with during the inspection gave us positive comments on how they looked forward to visiting the 'club' and of how well they were supported by staff. Drylaw Rainbow Club Day Centre, page 9 of 25
Taking carers' views into account Some of the comments made by relatives/carers in the pre inspection questionnaires were as follows: "They must be ticking all the right boxes. Mum really looks forward to going and always and always says how she enjoys it". "This is a fantastic service, not only for the clients but for their carers which are mostly family members like myself. There is always someone there to lend an ear or helping hand". "All the staff I have met are extremely friendly, respectful and helpful to my husband. I am satisfied he is well looked after at the Rainbow Club". "My father is well looked after and stimulated during his visits to Drylaw. He really looks forward to going there". "I am happy with the service provided for my husband and he is happy to attend" and "I am very happy with the support they give; they are always pleasant and good with mum, bus drivers included". We spoke with two family members during our inspection. They spoke warmly about the service and told us how their relative looked forward to attending. The stated that they saw that their relative was stimulated when they attended. Drylaw Rainbow Club Day Centre, page 10 of 25
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 We have assessed that the service was performing at an excellent level for this statement. To make our assessment we looked at records in the service, spoke with people using the service during the inspection and took into account responses in our questionnaires. There were a variety of ways that people could participate. For example, there was a complaint policy in place if people wished to use this. Surveys were conducted to gain the views of people and to gain ideas of how the service could improve. This was last completed in October 2014. It was clear that the service was open and welcoming to comments and suggestions from people. The manager had an open door policy and this was seen to be well used. Family members, people who used the service and neighbours would 'drop in'. Families and local businesses showed appreciation of the service by giving welcomed, generous donations. The following is three recommendations made at the last inspection and the actions taken to meet these. 1. 'The Manager should develop a written participation strategy for the service to outline methods by which the service would obtain and respond to the views of service users and relatives/carers. This should include how service users and relatives/carers will be involved in assessing and improving the quality of the overall Drylaw Rainbow Club Day Centre, page 11 of 25
service: the quality of care, the quality of the environment, the quality of staffing and the quality of management and leadership. This is in order to meet The National Care Standards, Support Services - Standard 8 Making choices, and Standard 12 Expressing your views.' Action taken The participation strategy had been reviewed and dated in September 2014. This set out, in good detail, the methods and ways that people using the service could express their views and make suggestions for improvement. Included in the participation strategy was a 'wish list' which was used to organise activity and outings which were meaningful for the service users. This recommendation was met. We were given examples of how service users' wishes had been achieved, for example with an outing on a barge. 2. 'The Manager should consider the use of an action plan following all service user meetings and the twice yearly surveys to record how any issues raised will be progressed, in what timescale and by whom. This is in order to meet The National Care Standards, Support Services - Standard 8 Making choices, and Standard 12 Expressing your views.' Action taken The manager had implemented action plans where necessary. This recommendation was met. 3. 'The Care Provider should ensure that all policies and procedures have been endorsed and approved for use in the service. This should include a start date and review date for each policy and procedure. This is in order to meet The National Care Standards, Support Services - Standard 2 Management and staffing.' Action taken We looked at a sample of policies used in the service. These were dated and had a date of when they were due to be reviewed. This recommendation was met. Areas for improvement From the questionnaires returned to us, there were a number of people who told us that they were unaware of the complaint policy of the provider or that they could make a complaint to us. We saw that the complaint policy was displayed in the home. However, there was some old information which could distract from information that was up to date. The Drylaw Rainbow Club Day Centre, page 12 of 25
manager addressed this at the inspection. The 'welcome pack' given to all service users included a complaint procedure and this gave clear guidance on how to raise a complaint if people wished. The manager planned to reinforce the complaint procedure in the service. We will review the comments at the next inspection. We have concluded that the outcomes experienced by service users are of a very high quality. It was evident that there were formal means of gaining views of service users, however there were very good examples of how informal discussion was an important part of the day to day operation of the service. The manager should continue to act on the views of people using the service and their families to maintain this grade. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Statement 5 We respond to service users' care and support needs using person centered values. Service strengths We have assessed that the service was performing at a very good level for this statement. To make our assessment we observed interaction between staff and service users, took into account the responses in our questionnaires, spoke with staff and looked at records in the service. People told us in the questionnaires that they thought that the staff were respectful. We observed staff, volunteers and service users interact during our inspection. Staff and volunteers knew the service users well. There were very kind and caring relationships and there was fun and laughter throughout the day. Service users spoken with were complimentary about staff and told us that they were 'great'. We heard staff speak with family members on the phone and this was respectful and listening. The following recommendation was made at the last inspection: 'The service should continue to develop care and support plans and reviews to evidence on-going responses to changing needs or areas of need agreed through reviews. These should include what was discussed, agreed and who will progress any outcomes as a result of the care and support plan review. This is in order to meet The Drylaw Rainbow Club Day Centre, page 13 of 25
National Care Standards, Support Services - Standard 4 Support Arrangements.' Action taken We sample care and support plans. These were of a very good standard and written in a person centred way. The personal plan gave important information, such as other agencies who were involved in the care of the service user, key worker and advocate (if appropriate). Plans included the service user's preferences, how they could communicate and physical, social and emotional needs. Reviews of care dates were included and agreements signed. Underpinning the plan was the values of the service which stated: "I should be treated as an individual". "I should be asked about the services I need and be involved in making the choices I want" and "I should be supported to use the same local services as everyone else, wherever possible". We were given examples of how this had been achieved for some people, for example, one person was supported to visit the local hairdresser and all of the service users were invited to the golf club for a Christmas dinner. Staff in the service were coordinating and supporting people to attend. Areas for improvement The manager discussed how she wished to take the service forward and to progress activity and outings for service users taking into account the service users' 'wish list'. One person had answered in the service's survey that they thought that there could be an option of activity to suit their needs. The manager thought that this was now achievable since the deputy manager had been appointed. We will monitor progress at the next inspection. We have concluded that Drylaw Rainbow Day Centre had major strengths in respect of this statement. The service should take the opportunity to improve and strive to raise the performance to excellent. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Drylaw Rainbow Club Day Centre, page 14 of 25
Quality Theme 2: Quality of Environment 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 environment within the service. Service strengths We have assessed that the service was performing at a very good level for this statement. Information in Quality of care statement 1 is relevant to this statement. Areas for improvement Whilst there was a survey conducted in October 2014, this centred on care and the experience of using the service. There was no inclusion of issues relating to the environment. We acknowledge that the service is provided in part of church premises and the service will be restricted in what can be done to enhance the environment. However, we thought that the survey could ask whether people thought that it was clean and well maintained. We will monitor this at the next inspection. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths We have assessed that the service was performing at a very good level for this statement. To make our assessment we looked around the environment and looked at records kept in the service to show that there was a system for on-going maintenance and repair. The premises used for day care was mainly one large room with adjacent toilet and Drylaw Rainbow Club Day Centre, page 15 of 25
shower facilities. The manager told us about one service user who liked to spend time in the office with her as the main lounge could be busy. She was welcomed to do so and this meant that the service user and family were supported to make good use of the day care service. There was disabled access into and around the premises. We observed staff support and assist service users from the mini bus into the service. This was done with care and attention, going at the service users' pace. There were a number of wheelchairs used for transfers and the manager told us that these were checked on a daily basis and repairs made if there were any faults identified. The manager worked closely with the property maintenance person and any issues identified for repair was actioned. Improvements had been made in the facilities since the last inspection. This included installing shower facilities and upgrading the toilets. The toilets were clean and fresh with good supplies of soap, paper towels and pedal bins which helped reduce the possibility of cross infection. We saw lunch being served. This looked hot and appetising. This was served at appropriate temperatures as staff kept daily records of the temperatures of food before serving. Staff wore protective clothing, such as aprons and gloves when serving food. There was a range of policies and procedure in place and staff signed to say that they had read and understood the content. This helped staff to perform in their role following direction and guidance. Fire notices and instructions were displayed and each service user had an evacuation plan. There was a sign in book to show who was visiting the premises at any given time. There was a good number of staff and volunteers working in the service on the day of inspection to meet the needs of service users. Additionally, the manager and staff were aware of the policies relating to adult support and protection. Protection of vulnerable adult checks (PVG) was carried out and in place for all permanent staff. This was almost completed for all volunteers. Areas for improvement We have concluded that the manager has systems in place to ensure that the facilities are safe and that service users are protected. Whilst we saw that the main lounge was busy with little space to move around, we Drylaw Rainbow Club Day Centre, page 16 of 25
acknowledge that the manager had worked with the existing environment to try to make the experience for service users positive. This may restrict the development of the service. We were told that one volunteer was waiting for the PVG check to return. The volunteer was not working alone with service users and this reduced the risks. We will check that all people have up to date checks at the next inspection. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Drylaw Rainbow Club Day Centre, page 17 of 25
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 information in Quality Theme 1, Quality Statement 1 also relates to this statement. The service's survey of October 2014 had asked for people's views about staff and volunteers working in the service. There were no negative responses. Service users gave comments such as: "Excellent, I love them" when asked if staff promote dignity and independence and "bus drivers 100%". The self-assessment of the service told us that service users had been involved in the recruitment of staff. Areas for improvement Information in Quality of care and support statement 1 is relevant to this statement. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths To assess this statement we observed interaction between staff and residents, looked at records, took into account the views of people who responded to our questionnaires and spoke with service users and visitors to the service. We have assessed that the service was performing at a very good level for this statement. The outcomes experienced by service users were good. There were major Drylaw Rainbow Club Day Centre, page 18 of 25
strengths in this statement. This was particularly, in part, due to the level of commitment from the staff team who evidently wanted to ensure that the service users and their family had a positive experience of day care facilities. Staff directed the inspector to the National Care Standards for the service. Each staff member had a copy of the SSSC codes which sets out what is expected of them in their role as a social care worker. All staff were registered with the appropriate body. The manager had completed management qualifications. The staff team worked closely and communicated well at daily meetings. There was a range of training on offer in the service. This included moving and handling, first aid, food hygiene and infection control. We observed staff practice in some of these areas during the inspection and found some good practice, for example, in respect of infection control and moving and handling. The manager was aware of all training that had been undertaken by staff and knew when individuals were due to be updated in a specific area. The manager was aware of the process of reporting any concerns relating to adult support and protection and made notifications to us about significant events as required. The manager had planned for additional training, for example stress reduction and substance misuse, to ensure that staff were equipped to meet the changing needs of people who were referred to the service. Staff practice in assessing residents needs and record keeping was of a high standard. There was evidence of multi-agency working and staff kept in touch with other agencies and families to make sure that relevant information was shared about the service user. Staff used a communication book to make sure that each of them was aware of what was relevant on a day to day basis. We saw, for example, where the transport staff had found that a service user did not answer their door on the day they should attend the service. Records showed that this was promptly followed up and contact was made with the relative to make sure that the service user was safe. Areas for improvement The appointment of the deputy manager may help to maintain and raise the performance in the service, particularly in regard to ensuring that activity and outings are person centred and happen. We will monitor the impact of additional staffing at the next inspection. We have concluded that if this level of performance is maintained or enhanced, the grade can be improved. Drylaw Rainbow Club Day Centre, page 19 of 25
Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Drylaw Rainbow Club Day Centre, page 20 of 25
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 Information in Quality of Care statement 1 is relevant to this statement. Areas for improvement Information in Quality of Care statement 1 is relevant to this statement. We did not see particular ways in which people could participate specifically on the quality of the management and leadership of the service. The service should consider how to capture views relating to this in the surveys. We will review progress at the next inspection. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide Service strengths We have assessed that the service is performing at very good level for this statement. To make our assessment we looked at records in the service and spoke with the manager. We were kept informed of significant events that happened in the service as required. The manager had an overview of practice in the service. There were impressive systems in place for the organisation and delivery of care. Service user personal files were individual, well set out and maintained. Each file was colour coded to show the day that the service user attended and this linked to the key Drylaw Rainbow Club Day Centre, page 21 of 25
worker. Staff knew what was expected of them and there was allocation of duties highlighted daily. This gave staff the chance to have an all-round awareness of the needs of the service user. The manager met with the management committee on a monthly basis. Audits were carried out to identify areas for improvement. For example, the supplier of the lunches had recently been changed. In order to ensure that the supplier was meeting the preferences and taking account of the views of service users, daily comments were returned with the delivery boxes. This told the supplier what people liked and gave comments on the quality of food. Areas for improvement We have concluded that if this level of performance is maintained or enhanced, the grade can be improved. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Drylaw Rainbow Club Day Centre, page 22 of 25
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 No 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). Drylaw Rainbow Club Day Centre, page 23 of 25
5 Summary of grades Quality of Care and Support - 5 - Very Good Statement 1 Statement 5 6 - Excellent 5 - Very Good Quality of Environment - 5 - Very Good Statement 1 Statement 2 5 - Very Good 5 - Very Good Quality of Staffing - 5 - Very Good Statement 1 Statement 3 6 - Excellent 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 18 Oct 2011 Unannounced Care and support 4 - Good Environment Not Assessed Staffing 4 - Good Management and Leadership Not Assessed 18 May 2010 Announced Care and support 4 - 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. Drylaw Rainbow Club Day Centre, page 24 of 25
To find out more about our inspections and inspection reports Read our leaflet 'How we inspect'. You can download it from our website or ask us to send you a copy by telephoning us on 0345 600 9527. This inspection report is published by the Care Inspectorate. You can get more copies of this report and others by downloading it from our website: www.careinspectorate.com or by telephoning 0345 600 9527. Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: 0345 600 9527 Email: enquiries@careinspectorate.com Web: www.careinspectorate.com Drylaw Rainbow Club Day Centre, page 25 of 25