Annandale Bed and Bath Service Limited Support Service Care at Home 37 Well Street Moffat DG10 9DP Inspected by: Pauline Davidson Type of inspection: Unannounced Inspection completed on: 3 October 2012
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 27 5 Summary of grades 28 6 Inspection and grading history 28 Service provided by: Annandale Bed and Bath Service Limited Service provider number: SP2011011546 Care service number: CS2011286110 Contact details for the inspector who inspected this service: Pauline Davidson Telephone 01896 664400 Email enquiries@careinspectorate.com Annandale Bed and Bath Service Limited, page 2 of 29
Summary This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change after this inspection following other regulatory activity. For example, if we have to take enforcement action to make the service improve, or if we investigate and agree with a complaint someone makes about the service. We gave the service these grades Quality of Care and Support 3 Adequate Quality of Staffing 3 Adequate Quality of Management and Leadership 3 Adequate What the service does well The service has a dedicated staff team who are aware and responsive to individual service user needs. Communication between staff, service users, relatives and other health professionals was very good and there was an "open door" policy in place. Staff morale within the team was very good and the management team were approachable and supportive. We found that Annandale Bed and Bath Service Ltd (ABBS) had good systems in place to ensure that service users and carers could participate and improve the quality of care and support provided by the service. Annandale Bed and Bath Service Limited, page 3 of 29
What the service could do better The service needs to ensure that reviews of care and support plans are carried out consistently, at least once in each 6 month period. The service should introduce an internal quality audit system, to make sure the quality of the service is regularly monitored. The service should ensure that the individual personal plan contains clear reference to individual needs and personal preferences and sets out how these needs are to be met in a way the service user finds acceptable. The personal plan should contain enough information to enable staff to support service users in a person centred way, and evidence that service users have been involved in the development of the personal plan. What the service has done since the last inspection This is the first inspection since the service re-registered as a Limited Company on 30th May 2011. Conclusion We concluded that ABBS service users were well supported by a committed, motivated care and management staff team. The service was reliable and consistent and as a result, led to positive outcomes for service users. It continues to be responsive to service users and carers feedback and changing needs, and the service is held in high regard by service users and carers. The service should continue to work on its strengths while working on meeting the areas for improvement identified throughout this report. Who did this inspection Pauline Davidson Annandale Bed and Bath Service Limited, page 4 of 29
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 Requirements and recommendations If we are concerned about some aspect of a service, or think it could do more to improve its service, we may make a recommendation or requirement. - A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service but where failure to do so will not directly result in enforcement. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reforms (Scotland) Act 2010 and Regulations or Orders made under the Act, or a condition of registration. Where there are breaches of the Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Inspectorate. This service re-registered with the Care Inspectorate as a limited company on 30th May 2011. The service is based in Moffat and provides care at home to clients who live in the Moffat, Lockerbie and surrounding areas. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 3 - Adequate Quality of 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. Annandale Bed and Bath Service Limited, page 5 of 29
2 How we inspected this service The level of inspection we carried out In this service we carried out a medium intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection We compiled the report following an unannounced inspection. The inspection was carried out by Care Inspectorate Inspector Pauline Davidson. The inspection took place over two days, 15th August 2012 between the hours of 09.15 and 17.00 and 17th August 2012, between the hours of 09.30 and 15.00. Feedback was given to the Manager on 3rd October 2012. As requested by us, the care service sent us an annual return. The service also sent us a self assessment form. We issued 30 questionnaires to friends, relatives or carers of people who used the service. Twenty six completed questionnaires were returned to us before the inspection. In this inspection we gathered evidence from various sources, including the relevant sections of policies, procedures, records and other documents, including: The services's relevant policies and procedures relevant to the quality statements examined at this inspection. The services annual return and self assessment. Registration certificate. Individual personal plans of people who use the service. Risk assessments. Information folder for service users. Completed communication books. Complaints records. Accident and incident records Staff files and training records. Discussion with five service users within their own homes. Discussion with the Manager and Coordinator of the service. Discussion with two senior carers and two carers. The service's questionnaires that had been completed by service users, relatives and other professionals. Minutes of staff meetings. Annandale Bed and Bath Service Limited, page 6 of 29
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 Annandale Bed and Bath Service Limited, page 7 of 29
The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The service provided us with a completed Self Assessment, which included relevant information as part of the inspection process. However, the service had graded themselves a grade 5 for all the quality statements we inspected. As shown from the our grading at the conclusion of the inspection, the service's gradings did not reflect the quality of the service. Taking the views of people using the care service into account Service users were complimentary of the service they received. Service user comments from the questionnaires we received are detailed throughout this report. We spoke with five service users during our inspection and comments included: "I am very happy". "No complaints at all". "The staff are like a ray of sunshine". "The company always put the client first". "The staff are bright and cheerful". "I look forward to seeing the staff". Taking carers' views into account Comments from carers or relatives included: "I have peace of mind that my father is visited in the morning and that I will be contacted if they have any concerns". "I find most of the carers very good and they are always around when needed". "Very happy with the service". "Excellent service". Annandale Bed and Bath Service Limited, page 8 of 29
3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths We found that Annandale Bed and Bath Service Ltd had good systems in place to ensure that service users and carers could participate and improve the quality of care and support provided by the service. There was a "Client and Relative Involvement Strategy Policy" in place for service users and relatives and all service users had a copy of this in their information folder within their home. New service users were initially visited by the Manager or Coordinator and given a comprehensive information folder which included information such as: *The complaints procedure including details of the Care Inspectorate and blank complaints forms. *Involvement Strategy *Advocacy information *Quality Assurance Statement *Aims and Objectives of the Service During this visit, the service user's needs would be discussed and this would be reflected in their individual care plan. Each service user had a contract in place detailing the agreed times of the visits and this was signed and dated within the folder. Service users and carers were given the opportunity to comment and express their views on any aspect of the service provided during the review process. Annandale Bed and Bath Service Limited, page 9 of 29
The service had undertaken a quality questionnaire six months ago. A total of 32 questionnaires were returned out of 35 and all clients, carers and/or relatives who had completed the questionnaire were extremely happy with the quality of care and support given. Comments included: *"Peace of mind - all little problems are solved right away" *"Better for everyone is the working together to get the best care" *"Very satisfied with the service" We confirmed that the service had fed back to service users and carers the outcome and comments of the quality questionnaire. All feedback was positive and at this time and there was no further action required. A quality questionnaire had also been sent to other people involved in the care and support of the service provided, such as GPs, District Nurses and Pharmacies. Once this was analysed, the outcome was again fed back to service users and carers. The service had an "Open Door Policy" and service users, families, carers and support staff could come in at any time. We observed support staff coming into the office and passing on comments or suggestions from service users at their request. There were recording systems in place through a communication book, and we evidenced regular contact with service users, carers, relatives and support staff and any further action taken. The Manager had recently arranged for an "afternoon tea" in a hotel, for service users and carers, and provided transport and support staff if required. This proved to be very successful and gave service users the opportunity to get together and express their views and suggestions. We saw testimonials from service users and families thanking the Manager and the support staff for their support, and also thanking them for the opportunity to get together at the afternoon tea event. We observed staff offering service users choice of the way they wanted the care and support to be carried out during visits. Service users we spoke with were confident, and gave examples of how staff and the Manager listened to them and responded to their needs. Service users told us that they had contacted the office in the past and their requests were dealt with in a courteous and timely manner. Of the 26 service users and relatives who had completed questionnaires for us, eight strongly agreed and seven agreed that the service asked for their opinions on how it could improve. Five service users disagreed and three didn't know if the service asked for their opinions on how it could improve. Annandale Bed and Bath Service Limited, page 10 of 29
Eleven service users strongly agreed and ten agreed that the service checked with them regularly that they were meeting their needs. Two service users didn't know. Areas for improvement The Manager had identified, after the success of the "group afternoon tea", that she would look at organising further ways of involving service users and carers in a group such as a "focus group" or "forum". The Manager should also look at the questions on the service questionnaires sent to service users and relatives. These did not all reflect the quality of the care and support provided and some of the questions were not relevant to existing service users. Service users had, however, commented on the quality of the care and support using the further comments box at the end of the questionnaire. Within the returned Care Standards Questionnaires, five people "disagreed" and three "did not know" if the service asked for their opinion about how they could improve. Two service users "did not know" if the service checked with them regularly that they were meeting their needs. There was a service user and relative involvement strategy policy in place but this was not clear on exactly how people would be involved and methods of participation, such as: *Through the development of the personal plan and review meetings. *Through discussion with service users and carers with support staff, coordinator and Manager. *Through quality questionnaires. *Through arranged service user "group" meetings and planned social events. Not all service users spoken with were aware of the involvement strategy, but we did, however, find that this information was clearly contained within each individual's information folder. The service should further develop their involvement strategy to include the various methods and ways in which service users and carers can "have their say" about the overall quality of the service. The service needs to ensure that all service users and carers are aware of this, and the support they can receive to improve the quality of care and support provided. (See recommendation 1) Of the four members of staff interviewed, only one was aware of the service user and relative involvement strategy policy. (See recommendation 2) Annandale Bed and Bath Service Limited, page 11 of 29
Whilst the service had a system in place to facilitate reviews of care and support for the service users every six months, we found these had not been consistently achieved for all service users at the time of inspection. Of the six personal plans sampled, the majority of reviews were carried out by the Social Work Department and included in the service users file in the office. There was no evidence that the service was carrying out regular six monthly reviews, that the service user had signed and received a copy of the review minutes, or that the personal plan had been updated, or remained the same, as a result of the review. One personal plan was sampled for a service user who had been using the service for two years, but there was no evidence of a review of care or of the personal plan having been carried out during this time. (See requirement 1) Grade awarded for this statement: 4 - Good Number of requirements: 1 Number of recommendations: 2 Requirements 1. The provider must ensure that a review of care and the personal plan is carried out at least once in every 6 month period and that the service user is involved in the review process. The service user should sign and receive a copy of the review minutes. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI2011/210) Regulation 5.(2) (b) (i) (ii) (iii) Personal plans Timescale: within 24 hours of receiving this report. Recommendations 1. The provider should further develop their involvement strategy to include the various methods and ways in which service users and carers can "have their say" about the overall quality of the service. The service needs to ensure that all service users and carers are aware of this, and the support they can receive to improve the quality of care and support provided. National Care Standards, Care at Home, Standard 4.5 Management and Staffing and Standard 11 Expressing Your Views. Annandale Bed and Bath Service Limited, page 12 of 29
2. All care staff should receive training in the Involvement and Participation Strategy. Staff should be aware of the various methods in which service users can have their say and how they can support service users and carers to improve the quality of care and support provided. National Care Standards, Care at Home, Standard 4.5 Management and Staffing and Standard 11 Expressing Your Views. Annandale Bed and Bath Service Limited, page 13 of 29
Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Each service user had an individual personal plan. This was evidenced by visiting service users within their own homes. The personal plans contained relevant information about the service user including, next of kin, GP, social worker, emergency contact and any medical details such as dietary requirements, allergies and medication. Information on mobility, communication, memory and personal care needs were also recorded. The reason for referral was recorded and a care plan was in place from the local authority which detailed agreed tasks to be carried out at each visit. Of the 26 service users and relatives who completed questionnaires for us, 23 agreed that they had a personal care plan which contained information about their support needs. Two people did not know if there was a personal plan. Service users spoken with said they could talk to staff if they had any health concerns. They described how staff were aware of their healthcare needs and were vigilant in monitoring any changes. Service users felt confident that staff had the skills and knowledge to meet their healthcare needs and would contact the relevant professionals if and when appropriate. Within the personal plan, there were medication consent forms signed by the service user, or representative, giving clear direction and authorisation for staff to administer medication as directed by the medication policy. Service users also had a copy of the medication policy in their information folder. Medication records sampled were accurate and well maintained, detailing the medication administered, the time and dosage, including the initials of the care staff carrying out the task. All staff had undertaken Medication training and First Aid. Staff spoken with gave examples of supporting individual service users with healthcare needs and of working collaboratively with the GP, district nurses, dietitians and other healthcare professionals, to ensure the service users were receiving the appropriate healthcare. We found evidence in personal plans that staff had identified individual, changing healthcare needs and had referred these to the relevant healthcare professionals. We saw that individual's support reflected the changing healthcare needs and incorporated appropriate recording systems to monitor healthcare, such as food and fluid intake and the communication diary. Annandale Bed and Bath Service Limited, page 14 of 29
We saw that service users were receiving the hours of support designated to them by checking staff schedules of work and the rota system within the office against the agreed contractual hours. From this evidence we could see that each service user had a variety of support workers rather than a small team. Service users spoken with said "I have a variety of staff and I am happy with this" and "I am 100% happy with all the staff". We could see from the rota system that, although specific times had been assigned for each service user, the service was flexible to meet individual need. Staff spoke of service users times being changed to meet a changing healthcare need, or to accommodate social and leisure activities, such as attending a day centre. We saw that each service user was given the choice to have a weekly schedule so they knew the allocated worker in advance for each visit. The service users we spoke with told us that staff were very rarely late and if they were going to be late, the office would phone them and let them know. All service users spoken with confirmed that they always received their allocated visit, staff stayed the allocated time and that all tasks where undertaken during this time. Twelve service users who completed questionnaires for us strongly agreed that staff had enough time to carry out the agreed support and care and thirteen people agreed. One person disagreed. Areas for improvement It was identified through discussion with staff and the Manager that a "calling card" would be left at a service user's home if the carer could not gain access for the scheduled visit. There was no clear system or procedure in place to ensure that the appropriate action was taken to determine the health and welfare of the service user, if the carer could not gain access, or if the service user was not at home. (See requirement 1 ) We saw that risk assessments were in place which included general risk assessments of the service user's home and individual risk assessments relating to the delivery of care, including moving and handling and nutrition. There was evidence that the risk assessments had been updated. However, on sampling service user files within their own homes, we found that the risk assessments were generic and often the same for each service user. For example, we found a risk assessment for a stair lift in each service user's file, but this was not applicable to the individual. (See requirement 2) Annandale Bed and Bath Service Limited, page 15 of 29
Although the care plan contained the relevant information for each individual service user, it did not contain clear reference to individual needs and personal preferences or set out how these needs would be met in a way the service user finds acceptable. The care plans did not contain enough information to enable staff to support service users in a person centred way, or evidence that service users had been involved in the development of their personal plan. The information within the personal plan was not held within the service user's office file. (See recommendation 1) Within the office, any records or daily notes relating to individual service users were all recorded in the communication book. This included all records such as telephone contact, changes in visit times, service user health care needs and all other issues relating to the service user. This made it difficult to monitor and audit individual healthcare needs, or any other issue relating to the service user. (See recommendation 2) Although carers were aware that the time varied for scheduled visits to service users on certain days, the times were not recorded, for every service user on the carer rota. There was no record of arrival and departure time recorded by carers in the daily communication books to confirm this. Service users spoken with confirmed that carers always arrived for the scheduled visit, and stayed for the allocated time, and that they would contact the office if the carer did not arrive. There was no system in place to confirm and evidence that all visits had been carried out, particularly for those more vulnerable clients who were unable to contact the office. (See recommendation 3) The service's annual return stated that there had been two accidents and three incidents. We could only evidence one formal incident recorded but, when sampling service users files in the office, we discovered incident forms "misplaced" in a service users file. Records of incidents were also discovered handwritten on pieces of paper, not on incident forms, and then filed away in the service users file. There was no system in place to record or audit accidents and incidents or any follow up action taken. (See recommendation 4) The medication policy made no reference to the Dumfries and Galloway Guidelines for Home Carers Assisting Older Service Users with Medication or the levels of support. (See recommendation 5) Annandale Bed and Bath Service Limited, page 16 of 29
Grade awarded for this statement: 3 - Adequate Number of requirements: 2 Number of recommendations: 5 Requirements 1. The provider must ensure that there is an effective system in place which ensures the appropriate action is taken if a carer cannot gain access to a service user's home. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI2011/210) Regulation 4 (1) (a) A provider must make proper provision for the health, welfare and safety of service users: 4 (1) (b) A provider must provide services in a manner which respects the privacy and dignity of service users. Timescale: within 24 hours from receipt of this report. 2. The provider must ensure that risk assessments reflect current individual need and identified risk. Service users should be fully involved in the risk assessment process and these should be reviewed as and when necessary. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI2011/210) Regulation 4 (1) (a) A provider must make proper provision for the health, welfare and safety of service users: 4 (1) (b) A provider must provide services in a manner which respects the privacy and dignity of service users. Timescale: 8 weeks from receipt of this report. Recommendations 1. The provider should ensure that the individual personal plan contains clear reference to individual needs and personal preferences and sets out how these needs are to be met in a way the service user finds acceptable. The personal plan should contain enough information to enable staff to support service users in a person centred way, and evidence that service users have been involved in the development of the personal plan. All information within the personal plan should also be contained within the office to allow future auditing of this information. National Care Standards, Care at Home, Standard 3, Your personal plan. Annandale Bed and Bath Service Limited, page 17 of 29
2. The provider should ensure there is a system in place to record, monitor and audit individual service user notes and records. National Care Standards, Care at Home, Standard 4 Management and Staffing. 3. The provider must ensure that a reliable system is in place to confirm and evidence that visits have been carried out, including a record of arrival and departure time. The system should ensure that service users receive their care and support at the time and duration that are set out in the agreed care plan and contract. National Care Standards Care at Home, Standard 4.5 and 4.6, Management and Staffing. 4. The Manager should ensure that accident and incident reports are completed by staff at all times. They should contain clear and detailed information about what happened before, during and after the accident/incident and the actions taken. There should be a system in place to audit accident/incident forms before adding them to individual files. These should be used to make changes to care plans and risk assessments. National Care Standards Care at Home, Standard 4.1 Management and Staffing. 5. The Medication Policy should be reviewed and updated to cross reference and refer to The Dumfries and Galloway Guidelines for Home Carers Assisting Older Service Users with Medication. National Care Standards Care at Home, Standard 8.3 Keeping Well Medication. Annandale Bed and Bath Service Limited, page 18 of 29
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 The comments we have written in Quality Statement 1.1 also apply to this statement. Areas for improvement We have given this statement the same grade as Quality Statement 1.1 Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Annandale Bed and Bath Service Limited, page 19 of 29
Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths The support team was well established and many of the carers had worked for the organisation for many years. Carers spoken with said that the morale within the staff team was very good and they were all supportive of each other. All carers spoken with said the Management was very supportive, approachable and that they felt valued within their role. Staff meetings were held on a regular basis and staff said that they could contribute to these and their views and opinions were listened to. Staff confirmed that they were able to give their input to the meetings and any issues or concerns were always dealt with. We confirmed this by looking at the minutes of the meetings which were held weekly for the Lockerbie area of the service and fortnightly for the Moffat area of the service. We were able to see that staff had completed induction training and shadowing of service users before supporting them on their own. New staff underwent a staff work performance, approximately eight weeks after commencing work, and their performance would be monitored thereafter through the spot check process. Staff practice and areas for development were being identified through the spot check process. The manager could then see where a staff member was observed to need further training or development. We could see that staff were welcomed and found the management supportive and approachable through the open door policy. Staff regularly came into the office to be updated after days off, or for an informal chat with the Manager or Coordinator. Staff told us there was an on call system in place for out of hours, which they found very supportive. Areas for improvement The service's mandatory training does not include, Adult Support and Protection, Infection Control or Food Hygiene. Taking into account the regular personal care tasks and food preparation undertaken by staff, this training should be included in the mandatory training programme. Several support staff spoken with did not know about the Adult Support and Protection Procedure, or their role and responsibilities in relation to this. On sampling a service user's file, we became aware, through incidents recorded, that staff were supporting a service user with Dementia, who also displayed verbal and physical aggression. Not all staff had received training in Dementia or challenging behaviour. Annandale Bed and Bath Service Limited, page 20 of 29
Although mandatory moving and handling training was booked for two new carers, both carers were supporting clients with mobility needs and moving and handling equipment was being used, prior to them having undertaken the training. We discussed this with the Manager during the inspection who told us that training was difficult to access straight away, and until such time that the carers could attend a moving and handling course, they would always work as the "second carer". This means that they would always be undertaking moving and handling tasks and using equipment, under the supervision of an experienced carer with training and experience in moving and handling. (See requirement 1) The service had a policy on the Protection of Vulnerable Adults, but this did not contain clear, accurate up to date guidelines or make reference to The Adult Support and Protection (Scotland) Act 2007. (See recommendation 1) Files were sampled for two new members of staff. These confirmed that two references were not obtained. Both staff files had only one reference, which was not from the most recent employer, and one was written on a piece of notepaper. We could, therefore, not find evidence of authenticity or to verify who the reference was from. Where convictions were highlighted on PVG checks these had been discussed, but not risk assessed or recorded. The service's policy on recruitment and selection contained reference to the regulator in England. The provider needs to review and update the policy to ensure that it is referenced to Scottish Regulations and the relevant National Care Standards currently in operation. The policy should clearly state that two written references, one of which needs to be from a previous employer, are obtained prior to an offer of employment. (See requirement 2) New staff members had undergone induction training and the Manager explained how they had shadowed experienced carers when supporting service users prior to working alone. We could not find evidence of the structure of the shadowing shifts, and whether this was planned to reflect the service users the carers would be supporting. There was no recording of the shadowing shifts, or further discussions with the carer to determine if further training needs or support were identified. (See recommendation 2) Annandale Bed and Bath Service Limited, page 21 of 29
Although the service was carrying out spot checks to observe and discuss staff performance, there was no formal system in place for staff 1:1 supervision, or a supervision policy. There were no clearly detailed records of discussions held and action plans in place, and it was difficult to review and evaluate individual staff performance. Staff spoken with seemed confused as to the meaning of supervision. The general consensus was that this was when the spot check was undertaken. All staff spoken with agreed that they would like to have 1-1 supervision sessions, and a chance to sit down with the Manager on a more formal basis. Any issues highlighted within the spot check could also link in with the supervision process. (See recommendation 3) Grade awarded for this statement: 3 - Adequate Number of requirements: 2 Number of recommendations: 3 Requirements 1. The service must ensure that Adult Support and Protection, Infection Control and Food Hygiene are included in the mandatory training programme. All staff must attend these courses and updates as and when required. The service must ensure that all staff receive training to meet individual service user needs, in particular Dementia, Challenging Behaviour and Moving and Handling. The service must ensure and evidence, that carers without up to date moving and handling training are supervised by experienced staff with an up to date moving and handling certificate. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI2011/210) Regulation 15 (a) Staffing - a provider must ensure that at all times suitably qualified and competent persons are working in the care service: (b) (i) ensure that persons employed in the provision of the care service receive training appropriate to the work they are to perform. Timescale for implementation: within 3 months from receipt of this report. Annandale Bed and Bath Service Limited, page 22 of 29
2. The provider must ensure that safe and effective systems are in place for the recruitment of new staff. The provider must ensure that: *Two written references are obtained for all new employees, one of which should be from the most recent employer. The provider must be able to verify the authenticity of the reference. *Where convictions are highlighted on PVG applications, there is evidence of these being discussed with the employee, a risk assessment being undertaken and the information accurately recorded. *The Recruitment and Selection Policy and procedure is reviewed to reference Scottish Regulations and should contain reference to current legislation. The policy should clearly state that two written references must always be obtained and one must be from the previous employer. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI2011/210) Regulation 9 (1) Fitness of Employees: A provider must not employ any person in the provision of a care service unless that person is fit to be so employed. Timescale for implementation: within 2 weeks from receipt of this report. Recommendations 1. The service should review and update their policy for the protection of vulnerable adults, to take into account the Adult Support and Protection (Scotland) Act 2007. National Care Standards, Care at Home, Standard 4 Management and Staffing. 2. The service should ensure that shadowing shifts are structured, planned and recorded, as part of the induction process and that the Manager has further discussions with the carer to determine if further training needs or support are identified. National Care Standards, Care at Home, Standard 4 Management and Staffing. 3. The service should implement a Supervision Policy and ensure all staff receive regular supervision. The discussions held and agreements made should be recorded and signed by both parties. National Care Standards, Care at Home, Standard 4 Management and Staffing. Annandale Bed and Bath Service Limited, page 23 of 29
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 The comments we have written in Quality Statement 1.1 also apply to this statement. Areas for improvement We have given this statement the same grade as Quality Statement 1.1 Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Annandale Bed and Bath Service Limited, page 24 of 29
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 service had a complaints policy and procedure and service users explained that they would know how to make a complaint. The complaints policy was included in each individual service user information folder, along with a blank complaints form readily available. Service users spoken with confirmed that they were aware of how to make a complaint. The service had undertaken a quality questionnaire 6 months ago. A total of 32 questionnaires were returned out of 35 and all clients, carers and/or relatives who had completed the questionnaire were extremely happy with the quality of care and support given. (see Quality Statement 1.1) The service had issued a quality questionnaire 6 months ago to other professionals, including GPs, District Nurses and Pharmacists to assess the quality of the service provided. The feedback was very positive and the Manager had feedback the results to the service users. Comments included: *"You have defined what excellence in care should be" (GP) *"Very useful service providing genuinely caring staff. Good communication with surgery" (GP) *"We have a good rapport with the staff and communication has improved" (Community Nurse) *"Regular contact with the service helps communication and improve the outcomes" (Pharmacy) Seventeen service users who completed questionnaires for us strongly agreed that they were overall happy with the quality of care and support they received from ABBS, and nine people agreed. Areas for improvement The service had issued a staffing questionnaire to ask for staff feedback on the quality of the service. The questionnaires had then been filed into individual staff files but there was no collation, action plan or feedback to staff as a result of these. The service should consider ways of how they can feedback to staff the outcomes and actions of any further questionnaires. It was established that if a complaint was received, this would be dealt with as the directed in the services complaints procedure, and then filed. We discussed with the Manager the need to improve on the system used to monitor incoming complaints, and the outcomes. Annandale Bed and Bath Service Limited, page 25 of 29
There was no system in place to audit and monitor the quality of the service. An audit of the systems in place, such as the care plans, reviews, communication diaries, accidents and incidents and complaints, would enable improvements to be identified and acted on. (See recommendation 1) Staff files were disordered making it very difficult to find specific information for auditing purposes and they held old, out of date information and training certificates. There were PVG forms in staff files which should not have been there. (See recommendation 2) Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 2 Recommendations 1. The service should introduce an internal quality audit system, to make sure the quality of the service is regularly monitored and include key quality indicators such as personal plans and reviews, accidents and incidents, complaints, daily care notes, staff files, including supervision and training. National Care Standards, Care at Home Standard 4, Management and Leadership. 2. The service should ensure that information held in staff files should be audited and collated to ensure that only up to date, relevant information is held, and the remainder archived. PVG records should not be retained beyond the date of when the information should have been removed. National Care Standards, Care at Home Standard 4, Management and Leadership. Annandale Bed and Bath Service Limited, page 26 of 29
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 none at this inspection 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 SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). Annandale Bed and Bath Service Limited, page 27 of 29
5 Summary of grades Quality of Care and Support - 3 - Adequate Statement 1 Statement 3 4 - Good 3 - Adequate Quality of Staffing - 3 - Adequate Statement 1 Statement 3 4 - Good 3 - Adequate Quality of Management and Leadership - 3 - Adequate Statement 1 Statement 4 4 - Good 3 - Adequate 6 Inspection and grading history All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Annandale Bed and Bath Service Limited, page 28 of 29
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 Annandale Bed and Bath Service Limited, page 29 of 29