Care service inspection report Full inspection Autism Initiatives UK Housing Support Service Perth Inspection completed on 23 June 2016
Service provided by: Autism Initiatives (UK) Service provider number: SP2004006462 Care service number: CS2009233458 Inspection Visit Type: Unannounced Care services in Scotland cannot operate unless they are registered with the Care Inspectorate. We inspect, award grades and set out improvements that must be made. We also investigate complaints about care services and take action when things aren't good enough. Please get in touch with us if you would like more information or have any concerns about a care service. Contact Us Care Inspectorate Compass House 11 Riverside Drive Dundee DD1 4NY enquiries@careinspectorate.com 0345 600 9527 www.careinspectorate.com @careinspect page 2 of 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 2 Quality of staffing 3 Quality of management and leadership 2 Weak Adequate Weak What the service does well The staff team knew people who used the service very well. There was very detailed information about the support that people required and how staff should provide this. What the service could do better We had significant concerns in relation to medicine management. See Quality Theme 1, Statement 3. The manager must ensure that personal plans are reviewed in consultation with the person and their representatives at least once every six months. Where action plans have been developed to help plan and prioritise areas for development and improvement, the manager must ensure that these effective and include clear timescales which are regularly reviewed and updated to reflect progress. page 3 of 30
The manager must ensure that the management team are aware of the requirement to notify the Care Inspectorate as described in our publication 'Record all services (excluding childminders) must keep' and notification reporting guidance. The Provider must ensure that the management team has the support and learning opportunities to provide effective management and leadership within the service. What the service has done since the last inspection The staff had continued to work closely with people to plan their care and support with them. It was disappointing however that we could see no progress in relation to addressing areas for improvement from the previous report and that previous action plans devised following previous concerns around medication management had been ineffective as actions had not been fully addressed. Conclusion It was evident that there were many positive outcomes for people who used the service. It was however of significant concern that areas for improvement reported through our last inspection had not been progressed and that action plans that resulted from previous areas of concern around medication had not been completed or any improvements sustained. The Provider must ensure that the local management team are supported to understand the importance of giving these areas the priority it requires to help improve outcomes for people. page 4 of 30
1 About the service we inspected Inspection report 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. This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April 2011. Autism Initiatives UK provides a combined Housing Support and Care at Home service to service users who have a supported tenancy, known as the Earn Project. This is a flexible service; the number of hours provided is based on identified needs of individual service users and is designed to provide a specialist support service for people on the autism spectrum. The aim of the organisation is to provide a supportive environment with the aim of developing people's independent daily living skills, self-esteem and confidence and ability to be a part of the life of the local community. page 5 of 30
Recommendations A recommendation is a statement that sets out actions that a care service provider should take to improve or develop the quality of the service, but where failure to do so would not directly result in enforcement. Recommendations are based on the National Care Standards, SSSC codes of practice and recognised good practice. These must also be outcomes-based and if the provider meets the recommendation this would improve outcomes for people receiving the service. Requirements A requirement is a statement which sets out what a care service must do to improve outcomes for people who use services and must be linked to a breach in the Public Services Reform (Scotland) Act 2010 (the "Act"), its regulations, or orders made under the Act, or a condition of registration. Requirements are enforceable in law. We make requirements where (a) there is evidence of poor outcomes for people using the service or (b) there is the potential for poor outcomes which would affect people's health, safety or welfare. Based on the findings of this inspection this service has been awarded the following grades: Quality of care and support - Grade 2 - Weak Quality of staffing - Grade 3 - Adequate Quality of management and leadership - Grade 2 - Weak This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website www.careinspectorate.com or by calling us on 0345 600 9527 or visiting one of our offices. page 6 of 30
2 How we inspected this service The level of inspection we carried out In this service we carried out a high 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 This report was compiled following an unannounced inspection of the service. The inspection was completed by two inspectors from the Care Inspectorate on 06, 07 and 23 June 2016. Feedback was provided to the management team on 23 June 2016. During this inspection we gathered evidence from a range of sources including; - nine care and support plans - daily planners - minutes of reviews - risk assessments - contact sheets - medication records - hospital support plans - health action plans - communication books - accident and incident reports - file audits - managers monthly reports We also spoke with the manager, two team leaders, a senior support worker and nine support workers. We received further feedback from staff, people who used the service and family members through care standard questionnaires and by email. page 7 of 30
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 report Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at www.firescotland.gov.uk page 8 of 30
The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self-assessment document from the provider. We were satisfied with the way the provider completed this and with the relevant information included for each heading that we grade services under. The provider identified what it thought the service did well, some areas for improvement and any changes it had planned. Taking the views of people using the care service into account People who used the service declined to meet formally with us during the inspection. We did however receive some feedback through care standard questionnaires prior to our inspection. One person commented that their support was sometimes affected by staff shortages. They confirmed however that they were happy with their support and that staff treated them with respect. page 9 of 30
Taking carers' views into account We received feedback from six relatives and welfare guardians through care standard questionnaires and by email. Two people told us that they were not happy with the quality of care and that staff did not have sufficient time to provide the support. Two people told us they didn't think staff have the skills to support their family member. 100% of the responses we received confirmed that staff treated people with respect. We were told that staff and the manager were approachable and could be contacted to discuss any concerns or issues. One person told us how they were working with staff to identify and plan more structured activities with their family member. 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: 2 - Weak Statement 2 We enable service users to make individual choices and ensure that every service user can be supported to achieve their potential. Service Strengths We considered a range of evidence presented in relation to this statement. We assessed the service to be operating at a good level of performance during this inspection. A grade of 'good' applies to performance characterised by important strengths which have a significant positive impact. This grade implies that the service should try to improve further the areas of important strength and take action to address the areas for improvement. Some of the important strengths included; Inspection report - Support plans were very detailed and provided information about how people could be supported to develop skills that would enable them to achieve their full potential. - We saw that information stories had been developed with people to help them understand situations. For example going to the dentist. This helped people to make choices and to express how they felt. - There was detailed information about the support people required to help them communicate effectively. page 11 of 30
Overall we thought that staff knew people who used the service well and this would help them to continue to develop and improve the service to help improve outcomes for people. Areas for improvement Care should be taken to ensure that plans are reviewed and updated as required. We saw numerous changes to support plans and information handwritten on records or on sticky notes which could potentially create confusion if sticky notes fell off or were mislaid. In addition, many of the amendments were not dated or signed and therefore it was difficult to track who had been consulted in relation to the changes. We have made a requirement about reviews under 1.3. We saw one plan where it described that someone had a welfare guardian and what this meant in relation to the support staff provided. The guardianship order had in fact expired and therefore the information was providing staff with inaccurate information about the support they could provide. This should be updated as a priority to reflect the current position and avoid any confusion. Feedback from people commented on the lack of structured activities that would help people to maintain or learn new skills, this included lack of activities within the home as well as opportunities to develop their social skills. The staff team should consider how this can be addressed for people. Grade 4 - Good Number of requirements - 0 Number of recommendations - 0 Inspection report page 12 of 30
Statement 3 We ensure that service users' health and wellbeing needs are met. Service Strengths We considered a range of evidence presented in relation to this statement. Although we saw some good examples relating to how people were supported to maintain their health and wellbeing, there was one area of support that raised significant concerns and resulted in this performance being evaluated as weak overall following this inspection. The strengths we saw included; - very detailed care and support plans which included person centred information about how staff should support the person and about how to communicate effectively with people. - people were supported to access a range of activities. - there were very good records of consultation with others in relation to care and support and the wider service. The area of concern was in relation to medication management. There had been a number of medication errors which had led to a large-scale investigation conducted by the local authority. Similar concerns had been investigated prior to our last inspection and it was evident that the actions agreed at that time had either not been progressed or had not been sustained. A further action plan had been developed which described how the provider would address the concerns. This included; - further medication training for staff - observations of practice in relation to medication management - source and implement an alternative recording system for the administration of medication - improved handover information page 13 of 30
We saw that the management team had started to address these actions during our inspection and we will continue to review this through future inspections. Areas for improvement A quality statement is evaluated as 'weak' where, though there may be some strengths, there are important weaknesses which cause concern. This grade implies the need for structured and planned action by the service. The medication action plan should be completed and agreed with all relevant parties. We have asked the manager to submit monthly progress reports to the Care Inspectorate that describes how the plan is progressing. We have also made a requirement in relation to medication management. (Requirement 1) We have also made a recommendation relating to medication (Recommendation 2) In our last report, we had identified an area for improvement in relation to the information within support plans about guardianship and we made reference to the Mental Welfare Commission guidance 'Working with the Adults with Incapacity (Scotland) Act. It was disappointing that this had not been considered further and we were not confident that staff had accessed this guidance. We have made a recommendation in relation to this (Recommendation 1) We were unable to confirm that care and support plans had been reviewed in consultation with relevant people at least once every six months and this was confirmed by the manager who had previously identified this and was planning reviews. We have made a requirement in relation to this. (Requirement 2) page 14 of 30
Grade 2 - Weak Requirements Number of requirements - 2 1. The provider of the care service must ensure that; 1. there is a system in place for staff to have adequate information to support them to monitor residents medication and the specific condition the medication is prescribed for. 2. that staff understand their role in, and accountability for monitoring medication and ensuring there is sufficient stock. 3. that staff administer medicines in a way that recognises and respects people's dignity and privacy taking into consideration the daily routine of the resident and the possible need for medication to be available for administration out with the set times of medication rounds 4. that staff understand their responsibility to keep accurate and current records of medicines [including quantity] for the use of service users which are received, carried over from a previous month, administered, refused, destroyed or transferred out of the service. 5. ensure there is a system in place for regular reviews of MAR charts to remove items no longer prescribed, used or needed 6. that if a regular medication is not given or taken that staff record the reason why along with any further action that was taken including the outcomes of the action. This is in order to comply with: SSI 2011/210 Regulation 4 (1)(a) - a requirement to make proper provision for the health and welfare of people, and (b) provide services in a manner which respects the privacy and dignity of service users. SSI 2011/210 Regulation 5(1) - a requirement to have a personal plan which sets out how the service user's health and welfare needs are to be met. page 15 of 30
Timescale for implementation: Within four weeks of receipt of this report. Inspection report 2. The provider must make sure that personal support plans are reviewed with each resident and their carers or representative if appropriate, at least once in each six month period to ensure that the care and support provided continues to meet the needs of each individual. The provider should keep a record of these meetings and the minute taken. Minutes should contain a summary of the discussion held, the decisions made as a result of the discussion and when this will be reviewed again. This is in order to comply with SSI 2011/210 Regulation 5 - Support Plans. Timescale for implementation - six months from receipt of this report. Recommendations Number of recommendations - 2 1. The manager should ensure that staff are aware of best practice advice in relation to working with adults with incapacity and that sufficient guidance is provided within personal plans to inform staff where a guardian has been appointed and how this influences the support they provide. National Care Standards - Care at Home - Standard 3 - Your personal plan 2. Where staff are making handwritten entries to medication administration records, these should be dated and signed and referred to the prescribers instruction. National Care Standards - Care at Home - Standard 4: Management and Staffing page 16 of 30
Quality Theme 3: Quality of Staffing Grade awarded for this theme: 3 - Adequate Statement 2 We are confident that our staff have been recruited, and inducted, in a safe and robust manner to protect service users and staff. Service Strengths We assessed the service to be operating at a good level of performance in relation to this statement. The service was able to evidence, as legal requirements and good practice, a start date of employment, together with details of the position held, a record of skills, experience, qualifications and details of an appointment. The service was aware of the need for social care staff to register with the Scottish Social Services Council (SSSC). The staff we spoke to described their induction to the service and their ongoing probationary period. Core training was delivered prior to new staff providing direct care and support for people. New staff were introduced to people who used the service through shadow shifts which provided support for the staff member as well as the supported person. The staff we spoke to spoke positively about the support they received from their colleagues during induction and in their ongoing employment. Areas for improvement The manager needs to ensure that the frequency of supervision and observation of practice expected during induction is completed and evaluated with staff to enable them to continue to gain skills and knowledge. Grade 4 - Good Number of requirements - 0 Number of recommendations - 0 page 17 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 considered a range of evidence relevant to this statement during this inspection. This included a range of records and documentation, discussions with and feedback from staff members, people who used the service, family members and other stakeholders. We assessed the service to be operating at an adequate level of performance. The grade of 'adequate' represents a standard where strengths have a positive impact on the experiences of people who use the service. However, while weaknesses will not be important enough to have a substantially adverse impact, they are constraining performance. This grade implies the service should address areas of weakness while building on strengths. The strengths we saw were; - We spoke with a number of staff throughout this inspection. They described how they felt supported within the staff team and by their colleagues. Staff demonstrated that they knew people who used the service well and that they wanted to continue to consider how the service can develop and improve to help improve outcomes for people. - Although team meetings had not taken place at the frequency planned, staff told us that they thought meetings were valuable and helped to share information within the team. - A supervision planner had been re introduced and one of the senior staff explained how this was used to help plan regular supervision for staff. page 18 of 30
- A training matrix was maintained within the service that confirmed the training that staff had received, what training was due and when training was booked. The Provider had recently introduced a learning and development worker who would assist the manager in ensuring that training was planned and delivered when required. Areas for improvement During this inspection staff morale was low. Staff did not always feel that they had been supported to help manage situations that they felt had been challenging. Where staff practice had been observed, staff told us that they did not always receive feedback from their line managers. Staff had not received regular planned opportunities for supervision with their line managers. At our last inspection we reported that supervision and team meetings were planned more regularly. It was therefore disappointing to see that there were significant gaps in both processes since our last visit. The staff we spoke to thought that these processes were a valuable support to them. (Recommendation 1) The training matrix viewed at inspection reflected significant gaps in some areas for staff. In particular medication training. It was described in a previous action plan and in the managers self assessment that all staff had received medication training however we saw that the frequency of refreshers had lapsed significantly outwith the stated frequency of every two years. This was however being addressed and dates were planned for refresher training. It is essential that the manager continues to manage the training plan to ensure that staff have regular opportunities to maintain and update their skills and knowledge. (Requirement 1) page 19 of 30
We were not confident that staff had sufficient knowledge in relation to working with adults with incapacity. Staff were not familiar with and some told us they had not seen the best practice guidance we highlighted at our last inspection. It would be good practice for staff to know when a legal order such as guardianship has been awarded and what this means for the person. The manager should ensure that staff have access to relevant best practice guidance that should influence their practice. (See recommendation 1, statement 3) Observation of practice in relation to medication management was planned to happen every six months. It would be good practice to include the outcome of the observation in supervision which would support reflection of performance and capture what worked well and what has been learnt from the observation and how this has impacted on practice. Grade 3 - Adequate Requirements Number of requirements - 1 1. The Provider must ensure that staff have training commensurate to their roles and responsibilities. This should include regular opportunities to update and refresh their knowledge and skills and in particular in relation to medication management. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011, SSI 2011/210 Regulation 15. page 20 of 30
Recommendations Number of recommendations - 1 1. The manager should ensure that staff have access to regular and planned opportunities for support. This includes supervision and team meetings. National care Standards - Care at Home - Standard 4 - Management and Staffing. page 21 of 30
Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 2 - Weak Statement 3 To encourage good quality care, we promote leadership values throughout the workforce. Service Strengths We thought that although there were opportunities for the workforce to develop leadership values, these were not being fully utilised to the advantage of the staff team or for people who used the service. Some of the strengths that could be further developed included; - There had been opportunities for staff to gain further experience in promoted posts in an 'acting up' position. - Staff had the opportunity to work as key workers and to take some responsibility for developing and reviewing plans for care and support. Inspection report - Staff regularly 'lone worked' - that is they worked alone supporting people. This requires staff to demonstrate a range of skills including leadership values to help ensure that support is provided consistently for people. page 22 of 30
Overall, the staff team demonstrated a level of knowledge and understanding that could be further developed to contribute more effectively to the development and improvement of the service. As previously reported under Quality Theme 3, statement 3, staff morale was low during this inspection and staff described not feeling supported or valued. The support mechanisms such as team meetings and supervision had been irregular and therefore there was limited evidence to help assess how leadership values were promoted throughout the workforce. The manager had however taken some steps to address this and we will continue to review this at future inspections. Areas for improvement The manager planned to introduce regular management meetings which would go some way to helping develop an effective management structure within the service which in turn would help to support and develop the staff team. There were however, a number of areas of concern resulting from this inspection that indicated that the management team may require further support and training in relation to roles and responsibilities. For example, we had concerns about the frequency of supervision, team meetings, reviews were outstanding and previous areas for improvement and action plans had not been progressed. These were all areas where we felt that by promoting leadership values throughout the workforce, the staff team could contribute to the development and improvement plans that the manager had developed. Grade 2 - Weak Number of requirements - 0 Number of recommendations - 0 page 23 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 There were a number of concerns highlighted during this inspection and reported throughout this report. This resulted in a grade of weak for this statement. There were a number of tools and methods available to help assess the quality of the service. These included; - Medication file audits helped to identify and issues relating to the management of medication. - Communication books contained information about any changes to care and support and were used to update the staff team. - Monthly managers reports had helped to identify gaps in supervisions and review meetings. - Accidents and incident reports were completed by staff and reviewed by a manager to help ensure that responses to incidents were as agreed through care and support plans and that any actions required to minimise the risk of actual or potential injury were minimised. - Observation of staff practice was an opportunity for staff and their managers to reflect on practice and would help to identify any difficulties or issues that require further discussion. This was also an opportunity to identify any further training needs for staff. - Team meetings provided a forum for staff to exchange information and to receive information. page 24 of 30
- A supervision planner was in use and reviewed weekly to help plan regular opportunities for staff to meet with their line managers and to reflect on their practice and personal development. - Review meetings provided opportunities for a range of people to contribute to the development of care and support plans. This included the person who used the service, family members and other relevant stakeholders. - An action plan had been developed to help plan and prioritise actions required to improve performance in relation to medication management. At the time of this inspection the management team were progressing with the actions described within the plan. Overall the range of tools available, if used consistently could be effective at contributing to the overall development and improvement of the service. Areas for improvement There are a number of concerns raised throughout this report that brings into question the effectiveness of current methods of quality assurance. The manager planned to introduce monthly managers audits and regular local management team meetings which could help to improve performance. We will review this at a future inspection. Where action plans have been developed it is essential that these are reviewed regularly to track progress or to make further arrangements to meet the areas for improvement identified. We have made a requirement in relation to quality assurance (Requirement 1). We clarified with the manager the requirement for them to inform the Care Inspectorate of events, incidents and accidents as described in our guidance 'Records that all services (excluding childminders) must keep and notification reporting guidance' which is available on our website. We had concerns in this area which we highlighted to the manager and we have made a requirement in relation to this (Requirement 2). Grade 2 - Weak Inspection report page 25 of 30
Requirements Number of requirements - 2 page 26 of 30
1. The Providers must make proper provision for the health and welfare of service users by ensuring that they have appropriate quality assurance systems in place and that these are used effectively to reflect on going review of the service. This is in order to comply with SSI 2011/210 Regulation 4(1)(a) - Welfare of Users. Timescale for implementation - one month from receipt of this report. 2. The Provider must ensure that all notifiable incidents are reported to the Care Inspectorate as per the guidance 'Records that all services (excluding childminders) must keep and notification reporting guidance.' This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 SSI 2011/210 Regulation 4(1)(a) Timescale for implementation: one week from receipt of this report. Number of recommendations - 0 4 What the service has done to meet any requirements we made at our last inspection Previous requirements There are no outstanding requirements. 5 What the service has done to meet any recommendations we made at our last inspection page 27 of 30
Previous recommendations There are no outstanding recommendations. 6 Complaints No complaints have been upheld, or partially upheld, since the last inspection. 7 Enforcements We have taken no enforcement action against this care service since the last inspection. 8 Additional Information There is no additional information. 9 Inspection and grading history Date Type Gradings 4 Jun 2015 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership 5 - Very Good 14 Jul 2014 Unannounced Care and support 6 - Excellent Environment Not Assessed Staffing 5 - Very Good Management and Leadership 5 - Very Good 7 Aug 2013 Unannounced Care and support 5 - Very Good Environment Not Assessed page 28 of 30
Staffing Management and Leadership 5 - Very Good 5 - Very Good 30 Jul 2012 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership 5 - Very Good 7 Jul 2011 Unannounced Care and support 4 - Good Environment Not Assessed Staffing 4 - Good Management and Leadership 4 - Good 8 Nov 2010 Announced Care and support 3 - Adequate Environment Not Assessed Staffing 4 - Good Management and Leadership 3 - Adequate page 29 of 30
To find out more This inspection report is published by the Care Inspectorate. You can download this report and others from our website. You can also read more about our work online. Contact Us Care Inspectorate Compass House 11 Riverside Drive Dundee DD1 4NY enquiries@careinspectorate.com 0345 600 9527 www.careinspectorate.com @careinspect Other languages and formats This report is available in other languages and formats on request. Inspection report Tha am foillseachadh seo ri fhaighinn ann an cruthannan is cànain eile ma nithear iarrtas. page 30 of 30