The Richmond Fellowship Scotland - Lothians - Care at Home Support Service 1a Eastfield Drive Penicuik EH26 8AY Inspected by: (Care Commission Officer) Carol Moss Type of inspection: Inspection completed on: 17 November 28 1/14
Service Number Service name CS27163765 The Richmond Fellowship Scotland - Lothians - Care at Home Service address 1a Eastfield Drive Penicuik EH26 8AY Provider Number dummy Provider Name SP246282 The Richmond Fellowship Scotland Inspected By dummy Inspection Type Carol Moss Care Commission Officer dummy Inspection Completed Period since last inspection 17 November 28 First inspection dummy Local Office Address South East Region Stuart House Eskmills Musselburgh EH21 7PB 845 68335 dummy 2/14
Introduction The Richmond Fellowship Scotland - East Lothian 1 is registered as a Housing Support and Care at Home service to provide care and support to individuals in their own homes. The service was initially set up to provide this support to one individual living in Musselburgh and the service continues to do so. The service is managed from an office base in Penicuik. The service has been registered with the Care Commission since 7 January 28. This is the service's first inspection. The provider, The Richmond Fellowship Scotland, is a charity which provides community based services for people who require support. They operate services across Scotland. The mission of the Richmond Fellowship Scotland is to provide high quality services that promote inclusion and maximise individual potential. Based on the findings of this inspection the service has been awarded the following grades: Quality of Care and Support - 5 - Very Good Quality of Staffing - 5 - Very Good Quality of Management and Leadership - 5 - Very Good This inspection report and grades represent the Care Commission s 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. Please refer to the care services register on the Care Commission s website (www.carecommission.com) for the most up-to-date grades for this service. Basis of Report This report was written following announced inspection visits to the office base on the 22 October and the 17 November 28. Before the Inspection The Annual Return The service was only registered in January 28 and therefore an Annual Return was not required. The Self-Assessment Form The service submitted a self-assessment form as requested by the Care Commission Views of service users One "How satisfied are you with your care service?" service user/relatives/carers questionnaire was sent out. Regulation Support Assessment The inspection plan for this service was decided after a Regulation Support Assessment (RSA) was carried out to determine the intensity of inspection necessary. The RSA is an assessment undertaken by the Care Commission Officer (CCO) which considers complaints 3/14
activity, changes in the provision of the service, nature of notifications made to the Care Commission by the service (such as absence of a manager) and action taken upon requirements. The CCO will also have considered how the service responded to situations and issues as part of the RSA. This assessment resulted in this service receiving a low RSA score and so a low intensity inspection was required. The inspection was based on the relevant Inspection Focus Area and associated National Care Standards, recommendations and requirements from previous inspections and complaints or other regulatory activity. During the inspection process Staff at inspection The inspection visit was carried out by CCO Carol Moss. Evidence During the inspection evidence was gathered from a number of sources. This included reviewing a range of policies, procedures, records and other documentation, including the following: internal audits/questionnaires participation strategy complaints procedure personal plan training plan training and supervision records minutes of staff meetings Discussion took place with the Manager and one member of staff. Inspection Focus Areas and links to Quality Themes and Statements for 28/9 Details of the inspection focus and associated Quality Themes to be used in inspecting each type of care service in 28/9 and supporting inspection guidance, can be found at: http://www.carecommission.com/ Findings are reported on under the relevant Quality Theme in conjunction with the National Care Standards, Care at Home and Housing Support Services and the Regulation of Care (Scotland) Act 21 and associated regulations. The Inspection Focus Area of Notifications is reported under Quality Statement 4.4. Each Quality Theme has associated quality statements, not all statements were inspected. Fire Safety Issues The Fire (Scotland) Act 25 introduced new regulatory arrangements in respect of fire safety, on 1 October 26. In terms of those arrangements, responsibility for enforcing the statutory provisions in relation to fire safety now lies with the Fire and Rescue service for the area in which a care service is located. Accordingly, the Care Commission will no longer report on matters of fire safety as part of its regulatory function, but, where significant fire safety issues become apparent, will alert the relevant Fire and Rescue service to their existence in order that it may act as it considers appropriate. Further advice on your responsibilities is available at www.infoscotland.com/firelaw Action taken on requirements since last Inspection 4/14
This was the service's first inspection. Comments on Self Assessment A completed self assessment document was submitted by the service. This was completed to a very good standard. It gave comprehensive and relevant information which reflected the findings of each Quality Theme and Statements. The service identified its strengths and stated areas for future development. View of Service Users No questionnaires were returned to the Care Commission. Views of the supported individual and relevant stakeholders were gathered from documented evidence in the individual's personal plan and included strategy meetings. This information is seen to be positive and is referred to in the main body of the report under the appropriate Quality Statement. View of Carers As views of service users. 5/14
Quality Theme 1: Quality of Care and Support Overall CCO Theme Grading: 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 The CCO sampled evidence that the service had presented in their QAF self assessment. The Richmond Fellowship Scotland had a Participation policy with comprehensive procedures and systems to enable the people that they supported and their relatives/carers to play an integral part in assessing and improving the quality of the care and support they received. A copy of this was reviewed by the CCO. Staff spoken with were knowledgeable of this policy and its procedures and systems. The service was able to evidence that they had been implementing these systems where appropriate. Returned "How are we doing?" questionnaires sent out by the service were seen. The results of these were found to be very positive. Comments included: "very person centred" "staff encourage individuality" "staff listen and respond appropriately" The supported individual's support coordination book and documentation in their Personal Support and Development Agreement (PSDA) were reviewed. These detailed discussions and feedback from the supported individual and other stakeholders. Meetings regarding reviews of care and support were documented. Examples of changes to practice following consideration of information gathered from supported individual and/or other stakeholders were seen. A comprehensive welcome pack had been given to the supported individual and their family. A copy of such was seen and found to include information about the organisation which included participation, a copy of the National Care Standards - housing support services and details of how to make a complaint. Areas for Development The service in their self assessment had identified areas for development. Within The Richmond Fellowship Scotland was a separate structure called FOCUS (Freedom of Choice United Services) which employed some of the people they support. Part of their role was service interviewing whereby they were involved in interviewing other supported people and then feeding back this information. The service were arranging for FOCUS to meet with the supported individual. The service intended to complete their organisation's audit tool, National Evaluation Tool (NET), that monitors quality of service provision. When this has been completed by the service it is validated by the organisation's Quality Team. The target date for completing these actions was given as 31 August 29. The progress and the outcomes of these will be followed up at future visits. CCO Grading 6/14
5 - Very Good Number of Requirements Number of Recommendations Statement 3: We ensure that service user's health and wellbeing needs are met. Service Strengths The individual supported by the service had a personal plan, known as a Personal Support and Development Agreements (PSDA). This was seen to detail the individual's support needs following comprehensive assessments. The personal plan indicated a holistic approach to care recognising both health and social needs. Healthcare professionals were seen to have been contacted and involved in developing plans of care where additional specialist support was required. Regular reviews of this care were seen. The personal plan evidenced that staff supported the individual to access and attend appointments and screening to maintain good health. The care and support provided to the individual was discussed with the Manager and one member of staff. The CCO found that staff were knowledgeable about the needs of the supported individual and on reviewing the personal plans found that the documentation reflected the care and support being provided. Staff training records indicated that arrangements were made for staff to attend training appropriate to the care and support relevant to this individual. Areas for Development The service was to continue using the very good support systems that it had established and to continue to seek out areas for development. CCO Grading 5 - Very Good Number of Requirements Number of Recommendations 7/14
Quality Theme 2: Quality of Environment Overall CCO Theme Grading: 8/14
Quality Theme 3: Quality of Staffing Overall CCO Theme Grading: 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 Methods of participation referred to in Quality Statement 1.1 enabled the individual supported by the service and other relevant stakeholders to be involved in assessing and improving the quality of staffing in the service. The "How are we doing?" questionnaires used by the service had questions relating to staff. The service had identified that the individual that they supported need time to build up a relationship with new staff. Staff spoken with confirmed that new staff were gradually introduced to the supported individual through working alongside an experienced permanent member of staff. Staff received regular supervision and an annual appraisal. Documented evidence of this was seen. Areas for Development The service had identified as an area for improvement specific training that would assist the staff to offer additional support to the supported individual. They had given a target date of 2 March 28 for completing this. CCO Grading 5 - Very Good Number of Requirements Number of Recommendations Statement 3: We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service Strengths The Richmond Fellowship Scotland had comprehensive policies and procedures to support staff in carrying out their responsibilities. These included induction, development training, supervision and communication. Staff spoken to were aware of how to access this information. Staff training records confirmed that these systems were being followed. Spot checks by management monitored the care and support been given. 9/14
The staff spoken with confirmed that new staff were given a comprehensive induction which included information about the National Care Standards and the Scottish Social Services Codes of Practice. They confirmed that they felt well supported and were very positive about the role/job that they did. Minutes of staff meetings were seen. These evidenced the sharing of good practices, feeding back of training that had been attended and informing of new policies and procedures. Areas for Development The service had identified in their self assessment that areas for development would include organising a team day. A skills audit would be completed and relevant staff supported to apply for the SVQ programme. A target date of 31 March 29 was given for completing these actions. Some of the training that staff did included completing a written questionnaire on the subject they had covered. It was recommended that staff date these questionnaires to evidence when they have been completed (recommendation 1). CCO Grading 5 - Very Good Number of Requirements Number of Recommendations 1/14
Quality Theme 4: Quality of Management and Leadership Overall CCO Theme Grading: 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 Methods of participation referred to in Quality Statement 1.1 enabled the supported individual in the service and other relevant stakeholders to be involved in assessing and improving the quality of the management and leadership of the service. The results from the "How well are we doing?" survey for each of the provider's services were drawn together to produce a national report. This was used to influence the development of the organisation. Examples of changes to the service through listening to feedback from stakeholders were seen recorded in minutes of review meetings. Areas for Development Developments reported under Quality Statement 1.1 would take forward these very good strategies. CCO Grading 5 - Very Good Number of Requirements Number of Recommendations 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 "Notifications" was an inspection focus area for this inspection. The following areas were explored and validated as part of the inspection process and reported on under this theme. The Manager was aware of their responsibilities to report to the Scottish Social Services Council (SSSC) the dismissal on the grounds of misconduct of any care staff member. They were aware that they must provide the SSSC with any information it may reasonably require and were aware of their responsibility to notify the Care Commission of matters of misconduct. The organisation had developed systems for monitoring key performance indicators and 11/14
targets which included staff supervision, appraisal and team meeting frequencies. The service were seen to follow these systems. The organisation also have an audit tool, NET, that monitors quality of service provision. The Manager had conducted spot checks to monitor staff practices and their approach to support. Details of the dates, times, findings and any additional action taken were seen recorded. Areas for Development Developments identified in Quality Statement 1.1 also applied to this statement. CCO Grading 5 - Very Good Number of Requirements Number of Recommendations 12/14
Regulations / Principles National Care Standards 13/14
Enforcement There has been no enforcement action against this service since the last inspection. Other Information No other issues were raised at this inspection visit. Requirements There were no requirements made at this inspection visit. Recommendations 1. It is recommended that staff date and sign completed training questionnaires. This takes account of National Care Standards, Standard 3 - Management and staffing arrangements. Carol Moss Care Commission Officer 14/14