Threshold Glasgow Housing Support Service Unit 5 Building 5 - The Doge's Templeton Business Centre Bridgeton Glasgow G40 1DA Telephone: 0141 551 9204 Inspected by: Kathy Godfrey Type of inspection: Unannounced Inspection completed on: 14 September 2012
Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 10 4 Other information 21 5 Summary of grades 22 6 Inspection and grading history 22 Service provided by: Church of Scotland Trading as Crossreach Service provider number: SP2004005785 Care service number: CS2008182309 Contact details for the inspector who inspected this service: Kathy Godfrey Telephone 0141 843 6840 Email enquiries@careinspectorate.com Threshold Glasgow, page 2 of 23
Summary This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change after this inspection following other regulatory activity. For example, if we have to take enforcement action to make the service improve, or if we investigate and agree with a complaint someone makes about the service. We gave the service these grades Quality of Care and Support 5 Very Good Quality of Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well The service has excellent service user participation. They are involved in every part of the service through various committees and forums. The service users are actively involved in the recruitment and interviewing of new staff and managers. The service makes excellent use of photographs and symbols to make paperwork easy read and accessible to as many service users as possible. What the service could do better The service have identified an area of improvement as the development of personal plan for adults with learning disabilities who have dementia. This would hold additional information, to the present plan, which would give additional information necessary to support a service user with dementia to live in their own home. The service are aiming to employ a lead staff member who specialises in autism. This would allow them to continue to develop this area of the service. What the service has done since the last inspection We could see significant improvement in service user participation such as involvement in the Care Inspectorate self assessment process. We observed the service continued to develop and take forward improvements identified by the service users. Threshold Glasgow, page 3 of 23
New personal plans had been developed which made greater user of photographs and symbols. This helped service users who have difficulty reading and writing, have more involvement in the plan. Conclusion Threshold Glasgow have excellent participation systems in place. Service users have opportunities to comment on all aspects of the service through weekly management meetings and regular service user forums and committees. Who did this inspection Kathy Godfrey Threshold Glasgow, page 4 of 23
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. The Care Inspectorate will award grades for services based on findings of inspections. Grades for this service may change after this inspection if we have to take enforcement action to make the service improve, or if we uphold or partially uphold a complaint that we investigate. The history of grades which services have been awarded is available on our website. You can find the most up-to-date grades for this service by visiting our website, by calling us on 0845 600 9527 or visiting one of our offices. 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." Threshold Glasgow was registered with the Care Commission on 11th March 2009 and is part of Crossreach. The service provides Housing Support and Care at Home for adults with learning disabilities. The service is managed from a base in the East End of Glasgow. The service currently support 38 service users within their own homes. The aims of the service are: To help you think about what a good life looks like for you To plan with you how you can get this good life To support you in ways that are respectful of your wishes and choices and not to over-support you with things you can do yourself Threshold Glasgow, page 5 of 23
Threshold Glasgow ethos is that service users lead and manage their service along with the rest of the management team. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 5 - Very Good Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 5 - Very Good This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website www.careinspectorate.com or by calling us on 0845 600 9527 or visiting one of our offices. Threshold Glasgow, page 6 of 23
2 How we inspected this service The level of inspection we carried out In this service we carried out a low intensity inspection. We carry out these inspections when we are satisfied that services are working hard to provide consistently high standards of care. What we did during the inspection We wrote the report following an unannounced inspection. The inspection was carried out by Kathy Godfrey over 2 days. Between 9am-5pm on the 12th and 9am-2pm on the14th September 2012. In this inspection we gathered evidence from various sources, including the relevant sections of policies, procedures, records and other documents including: Certificate of Registration Accident log Incident log Complaints/suggestions log Medication records Quality Assurance Audits Questionnaires Care plans of people who use this service Personal Activity Plans Staff training records Staff meeting minutes Staff supervision notes Self assessment document Newsletter We spoke with 4 service users, the Head of Service for Learning Disabilities, the Manager of the service, 3 senior support workers and 3 support workers. We also attended a meeting held by the Personalisation Project Board. 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 Threshold Glasgow, page 7 of 23
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 Threshold Glasgow, page 8 of 23
The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. We received a fully completed self assessment document from the service provider. We were satisfied with the way the service provider had completed this and with the relevant information they had given us for each of the headings that we grade them under. The service provider identified what they thought they did well, some areas for development and any changes they planned. There was evidence of service user involvement and limited staff involvement. This is an opportunity to comment on the quality of the service that is lost. Taking the views of people using the care service into account Taking carers' views into account Threshold Glasgow, page 9 of 23
3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths We found that this service was performing in an excellent way in the areas covered by this statement. We concluded this after we * Spoke with service users who use the service * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records The service had developed new personal plans. These were person centred and detailed service user support needs. This gave staff the relevant information to work in a consistent way. The plan included a weekly planner which detailed service user activities. This had photographs or symbols for every activity to be carried out. There was strong evidence of service user involvement in writing their plan. Service users we spoke with confirmed this. The service carried out 6 monthly reviews of the personal plan. These reviews gave the service user opportunities to discuss their service with their key staff and other agencies involved in the support. There was an action plan for any issues raised. Service users received a 4 weekly rota in advance. This showed a photograph of the staff member expected at the service users' home each day. If staff were off unexpectedly the service would let the service user know. The service users we spoke with all knew the complaints procedure and felt able to use it. The service had a pictorial complaints procedure which detailed who to complain to using photographs. This gave service users another way to access the Threshold Glasgow, page 10 of 23
complaints procedure. The service carried out direct observation of staff practice within the service users home. The service user was asked their opinion of the service they had received. This gave them an opportunity to comment on the quality of the support they received. Staff were given feedback on their performance through supervision. A major strength of this service was the involvement of service users in the decision making process. The service had developed excellent systems which involved service users in assessing and developing the service. These included: * Service users actively involved in the management committee * Service users hold their own meetings. Chaired by a service user these had their own agenda and pictorial minutes and encouraged all service users to take part. Issues were taken forward by the service users. * Service users and workers held regular meetings. These discussed practice issues such as effective Infection Control and at the service users request had a talk from the local police on safety. * Standards meetings held with service users and staff. These looked at the service strengths and areas for improvement for each National Care Standard. An action plan was drawn up for areas of improvement * Community group run by service users looked at how to continue to improve links within the community. This committee recently discussed and agreed to support MacMillan Cancer Support and are currently organising a coffee morning to raise funds. We observed that the service continued to develop and take forward improvements identified by service users. Areas for improvement The service should continue with their excellent work in this area. The service should continue to look at new ways to involve service users in the assessment of the service. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Threshold Glasgow, page 11 of 23
Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths We found that this service was performing very well in the areas covered by this statement. We concluded this after we * Spoke with service users who use the service * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records In addition: Inspection report continued The personal plans had details of current medication and all medication paperwork was filled in correctly. The plan also had health needs including details of health appointments. There was evidence that service users were supported to attend regular dentist, opticians and chiropody appointments. This contributed to keeping service users healthy. The plan also had information on exercise and how to gently encourage service users to have a healthy balanced diet. Service users we spoke with had been given advice on healthy diet choices and were encouraged to make healthy meals through menu planning. Staff completed a comprehensive mandatory training programme, which included infection control, food hygiene, fire safety, moving and assisting and Adult Support and Protection. New staff also completed shadow shifts, with more experienced staff. This gave opportunities for new staff to ask questions and be clear about service users needs and how to support them before working on their own. The service had a Safeguard Committee. Both service users and staff were involved in this. This committee had looked at Adult Support and Protection issues and had developed a DVD for service users and staff training. This raised service user awareness of protection issues and how to deal with them. Staff completed a weekly checklist in the service users' home. This included Health and Safety checks such as checking the smoke alarm and carbon monoxide alarm. This helped keep service users safe. Service users volunteered to be greeters at the organisation Day Opportunities Centre. They had received training and an ID badge. They sat at the reception desk and asked visitors to sign the visitors' book. Greeters we spoke with said they really enjoyed this. Threshold Glasgow, page 12 of 23
Areas for improvement The service has identified personal plans for service users with dementia as an area of improvement. The service are working on these at the moment. At present none of the service users have dementia but as they become older this plan would detail addition information needed to continue to offer support. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Threshold Glasgow, page 13 of 23
Quality Theme 3: Quality of Staffing Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths We found that this service was performing in an excellent way in the areas covered by this statement. We concluded this after we * Spoke with service users who use the service * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records The strengths for the service user and carer involvement, detailed under Quality Theme 1, statement 1 are the same for this statement. In addition: A major strength of this service was the active involvement of service users in recruitment. * The service users received training in how to do this. This included listening skills, about body language and how to ask questions. * The service users decided who would be interviewed by looking at application forms. The interview panel was all service users except for a senior staff member who was there for support if needed. The service users then graded potential staff members and came to a decision about who would be given the jobs. * Service users had developed job descriptions for support workers. This was in easy read language and told staff what service users expected from a worker. Service users completed surveys about the quality of their staff. This was carried out for each staff member and had their photograph on it. The survey asked about time keeping, attitude and staff practice. Any issues were followed through at supervision. An action plan was drawn up and discussed at next supervision. Service users we spoke with told us they were happy with the staff supporting them and they were always treated with dignity and respect. Service users told us they felt safe and one told us "nobody in here hits me. I'm not scared". Threshold Glasgow, page 14 of 23
Areas for improvement The service should continue with their excellent work in this area. The service should continue to look at new ways to involve service users in the assessment of the service. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Inspection report continued Threshold Glasgow, page 15 of 23
Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths We found that this service was performing very well in the areas covered by this statement. We concluded this after we * Spoke with service users who use the service * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records In addition: Inspection report continued Staff completed an induction programme. Staff we spoke with felt the training was very good and gave them the necessary skills to support the service users. Service users were involved in delivering staff training such as Infection Control. New staff were supported by a mentor. This was a senior staff member who offered guidance and support and ensured staff completed all mandatory training. We saw that there was a comprehensive data base regarding the range of courses and training which staff had completed or were going to attend. This is through a system called "EVOC". This is produced by Edinburgh Voluntary Organisations Council. We saw that the service had a training plan for both staff and service users. Staff each had a Professional Personal Development Plan. This included refresher dates and further training such as SVQ's. The service had their own accredited trainers for medication, dementia / alzheimers' and epilepsy. Staff received regular supervision sessions. These discussed practice, training and quality. These sessions gave opportunities for staff and supervisors to discuss any practice issues. Staff received an annual appraisal. These looked at values and professional competencies. They also gave the staff member and supervisor an opportunity to reflect back over achievements in the previous year and look forward to the coming year. The appraisal identified learning and development needs and how these would be met. Threshold Glasgow, page 16 of 23
Areas for improvement The service may want to continue to encourage staff to become computer literature. This would give them greater access to e-learning and the training database. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Threshold Glasgow, page 17 of 23
Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths We found that this service was performing in an excellent way in the areas covered by this statement. We concluded this after we * Spoke with service users who use the service * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records The strengths for the service user and carer involvement, detailed under Quality Theme 1, statement 1 are the same for this statement. In addition: Both service users and staff told us the management were approachable. Service user questionnaires asked for their views on the quality of care and how the service is managed. Service users were given feedback from these. This helped service users feel their views were listened to. Service users we spoke with agreed. The management team had sent out questionnaires to families. This asked for comments on the service being delivered. The results had an action plan developed for any issues raised. Feedback was given to families who attended the family meetings. This let families see that their comments were being listened to. Service users are on the Board of managers. We looked at minutes of these meetings and read that service users were actively involved in discussions. This gave service users an opportunity to influence the direction of the organisation. Service users and staff were involved in the Care Inspectorate self assessment process. This gave opportunities for service users and staff to comment on the quality of the service. Threshold Glasgow, page 18 of 23
Areas for improvement The service had asked families for suggestions for days and times they would be able to attend family meetings. These meetings were still poorly attended. The service may want to look at other ways to involve families in assessing the service. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Inspection report continued Threshold Glasgow, page 19 of 23
Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide Service strengths We found that this service was performing very well in the areas covered by this statement. We concluded this after we * Spoke with service users who use the service * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records In addition: The Head of Services carried out an annual Quality Evaluation. This looked at all aspects of the service such as staff training, Health and Safety and the Strategic Plan. Results of this audit were sent to the service manager who then developed a plan of action. The service had been awarded the "Customer Service Excellence Award". This is a government award and is a rigorous assessment of Customer satisfaction and is outcome based. Staff and service users were all involved in this and it included criteria such as quality of service and how the service dealt with problems. The service had an away day each year. This was for service users and staff to discuss Strategic Planning issues and decide goals for the future. There was a service user version, which was visual, in the office. This was changed as goals were reached and showed how the service continue to develop. Areas for improvement The service had identified an area of improvement as the development of a more service user friendly Quality Assurance document. This would give service users greater access to this and provide another opportunity to comment on the service. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Threshold Glasgow, page 20 of 23
4 Other information Complaints A complaint was partially upheld. The complaint was related to training. The required actions were: The manager should ensure that the policy on the administration of medication reflects the fact that staff will receive appropriate training prior to carrying out support. We looked at the medication policy and could see that this had been done. Training records should accurately reflect what training was offered, when this was offered and reasons for non-attendance to any training offered. We looked at the new system developed for keeping records of training attended and could see this had now been met. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in 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). Threshold Glasgow, page 21 of 23
5 Summary of grades Quality of Care and Support - 5 - Very Good Statement 1 Statement 3 6 - Excellent 5 - Very Good Quality of Staffing - 5 - Very Good Statement 1 Statement 3 6 - Excellent 5 - Very Good Quality of Management and Leadership - 5 - Very Good Statement 1 Statement 4 6 - Excellent 5 - Very Good 6 Inspection and grading history Date Type Gradings 8 Nov 2010 Announced Care and support 5 - Very Good Staffing Not Assessed Management and Leadership Not Assessed 4 Feb 2010 Announced Care and support 4 - Good Staffing 4 - Good Management and Leadership 4 - Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Threshold Glasgow, page 22 of 23
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 Threshold Glasgow, page 23 of 23