Care service inspection report

Transcription

1 Care service inspection report Full inspection Adalia Wood Care Home Service Orkie Miln Farmhouse Kingskettle Cupar Inspection completed on 25 May 2016

2 Service provided by: Adalia Wood Ltd Service provider number: SP Care service number: CS 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 page 2 of 35

3 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 4 Quality of environment 4 Quality of staffing 2 Quality of management and leadership 2 Good Good Weak Weak What the service does well The service provided a good standard of care and support for young people. Staff formed positive relationships with young people and their families and worked hard to build and maintain family contact. Through one-to-one discussions, the service had helped young people to make positive changes to their lifestyle which had led to improvements in their health and wellbeing and a reduction in antisocial behaviour. What the service could do better The service needed to make immediate improvements in the following key areas: - Establish a clear management structure. - Ensure that staff are recruited using robust safe recruitment procedures. page 3 of 35

4 - Establish a safe policy and procedure for physical restraint. - Put in place effective quality assurance systems. In addition, the service needs to develop an improvement plan, taking into account all of the areas identified for improvement in this report. What the service has done since the last inspection Not applicable. This was the first inspection of this service. Conclusion Adalia Wood is a recently established care home service which has, to date, provided a good standard of care and support to two young people, both of whom have made progress towards achieving positive outcomes related to the reasons for their placement. However, the service needs to make substantial changes to its current management and operational structures and to develop appropriate policies, procedures and practices in order to comply with current legislation, regulations and best practice guidance, as indicated in the recommendations and requirements made throughout this report. page 4 of 35

5 1 About the service we inspected Inspection report Adalia Wood Ltd is the registered provider of the service. The service is registered to care for up to five children aged between 12 and 16 years. The service is located in a rural setting in Fife but with good transport links to nearby towns. The premises is a large stone-built house with large gardens. It is light, clean and spacious throughout. It has five bedrooms for young people, one of which is en suite. There are sufficient additional bath and shower rooms for young people's use. There is a large farmhouse kitchen with table and chairs for shared meals and a very large lounge with comfortable seating, TV and computer area. In addition, there is a small annexe room which provides an additional quiet space for small meetings or family visits. There is a large garage which has been converted into a games room complete with pool table, table football and fitness equipment. The property is surrounded by gardens, mainly grassed, providing opportunities for football and other outdoor activities. In its statement of purpose, the service says that it will: - Offer a warm, supportive, nurturing environment to all young people. - Commit to working with each resident in his/her placement authority with regards to social workers, parents and all other associated professionals towards identifying, implementing and reviewing a plan of care which is largely unique to that resident and adequately reflects his/her needs at anyone time. - Ensure that each resident will enjoy a safe, secure, caring, and supportive environment which will nurture their education, stimulate their development and encourage their general wellbeing. - Provide leisure, encouragement, opportunity, and support with a view to each resident fulfilling their potential. page 5 of 35

6 - All young people staying at Adalia Wood will be listened to in order that their views can be taken into consideration. At the time of this inspection, two young people were receiving a service at Adalia Wood. Adalia Wood was registered as a care home service for children and young people on 27 August The Care Inspectorate regulates care services in Scotland. Information about all care services is available on our website at 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: page 6 of 35

7 Quality of care and support - Grade 4 - Good Quality of environment - Grade 4 - Good Quality of staffing - Grade 2 - Weak Quality of management and leadership - Grade 2 - Weak Inspection report 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 or by calling us on or visiting one of our offices. page 7 of 35

8 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 carried out an unannounced inspection of this service on 24 and 25 May Before the inspection, the service submitted a self assessment form as required by the Care Inspectorate. During the inspection, we met with: - one young person - three members of care staff - the depute manage (currently the acting manager of the service) - one of the service's three directors (currently working as a member of staff in the service). We also looked at a range of relevant documents, including: - two care plans - accident and incident records - complaint records - statement of purpose - information brochure for young people - risk assessments for premises, activities and outings - records of health and safety checks - notes of young people's meetings - notes of staff team meetings - notes of management meetings - staff recruitment records - staff training records page 8 of 35

9 - staff supervision records - child protection policy - staff recruitment policy - complaints policy. We also inspected the premises. 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 page 9 of 35

10 The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. This was completed in time for the inspection. The service provided very brief information which reflected the fact that this is a relatively new service and that the acting manager had only recently taken over the management role. However, the self assessment showed that the manager has a realistic understanding of the issues which the service needs to address to improve the quality fo the service. Taking the views of people using the care service into account We spoke to one young person during the inspection who had been at Adalia Wood for approximately six months. They expressed a very positive view of the service which they felt had helped them to turn their life around. They attributed this to staff spending time talking to them about previous lifestyles and behaviours and working with them to establish a better lifestyle. The young person was very proud of the fact that they had recently gained employment and that they had also become much fitter and healthier. They appreciated the fact that staff went running with them and went to the gym or page 10 of 35

11 swimming regularly. They liked the house, and their room, and took a pride in keeping this clean and tidy. Overall, they felt that this was a good place to be and compared it favourably to other establishments they had heard of. The young person would not hesitate to recommend it to someone who needed to be looked after away from home. Taking carers' views into account To date, we have been unable to speak to parents or carers to ask for their views of the service. The service described positive relationships and interaction with the parents of young people who were currently placed at Adalia Wood. page 11 of 35

12 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: 4 - Good 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 decided to look at this statement as it allows us to consider how well the service works with young people to make positive choices and to support them to achieve positive outcomes. From our discussions with young people and staff and from looking at care plans, reports and review minutes, we found that the service had the following strengths which had a positive impact on the young people's experiences in this service: We found that the service had encouraged young people to make choices and decisions about the environment and day-to-day living arrangements. They did this through house meetings or informal discussions. This allowed young people to influence things like menus, decoration of their rooms, purchase of equipment, and how they spent their leisure time. This resulted in young people generally feeling happy with the quality of their experience at Adalia Wood. Each young person had a personalised individual care plan which had been developed around the SHANARRI wellbeing indicators (that is, the nationally agreed indicators which help to assess how well young people are doing in page 12 of 35

13 terms of being safe, healthy, active, nurtured, achieving, responsible, respected, and included). There was clear evidence from the plans and from our discussions with young people that plans had been developed in conjunction with them and reflected their views and choices. Staff had actively engaged with young people to discuss the issues which had led to their admission to the service and had helped them to develop skills and strategies to improve their individual situations. The service had also provided transport for them to attend school and maintain family contact, frequently driving long distances to do this. There was clear evidence of positive partnership working with social workers and other professionals involved with young people. For both of the young people currently using the service, this had resulted in: - a reduction in offending behaviour - a reduction in misuse of alcohol or other substances - an improvement in physical health and fitness - improved school attendance for one young person - successfully gaining employment for another. Inspection report Although the numbers are small, we concluded that the service had reached a good standard in relation to this statement since there was clear evidence that young people were being given choices and had been supported to move towards achieving their potential. Areas for improvement Although some aspects of case recording were of a very good standard (notably the weekly summaries for social workers which were well written, evaluative, and reflected young people's views), there was room for the service to improve the quality of the care plans. They should do this by making sure that. - Entries in plans are clearly signed and dated. page 13 of 35

14 - Desired outcomes are SMART (that is, that they are specific, measurable, achievable, realistic, and have timescales within which they should be achieved). (See Recommendation 1.) Grade 4 - Good Number of requirements - 0 Recommendations Number of recommendations The service should improve the quality of the care plans by making sure that: - Entries in plans are clearly signed and dated. - Desired outcomes are SMART (that is, that they are specific, measurable, achievable, realistic, and have timescales within which they should be achieved). National Care Standards, Care Homes for Children and Young People - Standard 4: Support Arrangements Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths We decided to look at this statement as it allows us to consider how well the service is looking after young people in terms of their physical and emotional health and wellbeing. Also under this statement, we look at how well the service protects children and young people from harm or abuse. This year, the Care Inspectorate are looking page 14 of 35

15 specifically at whether services have appropriate policies and procedures in place in relation to child sexual exploitation (CSE) and checking that staff have the knowledge and information they need to support and protect young people from this particular form of abuse. From looking at care plans and from talking with young people and staff, we found that the service had the following strengths in relation to this statement: Young people were generally in good health. They were registered with primary healthcare services and were supported by staff to make and attend appointments with the doctor or dentist as required. Staff cared for young people when they didn't feel well and made sure that they sought and received treatment where necessary. One young person was attending the dentist for the first time in a long time with the support of staff. There were appropriate systems in place for storing and recording medication. A positive risk assessment and signed agreement was in place to allow a young person to manage their own medication, helping them to take responsibility for their own health and wellbeing. The service had actively promoted opportunities for young people to improve their physical health through regular activity and exercise. For one young person, this had been a key part of their care plan which had obvious benefits in terms of improved physical health, the development of positive leisure interests and routines and an improvement in self esteem. In relation to this, we could see that the direct involvement of an interested member of staff had a direct impact on the positive outcomes which this young person had achieved. Through a structured approach, with clearly defined rules and boundaries agreed with young people (including room searches where necessary) some young people had been helped to reduce alcohol and substance misuse. The service has a child protection policy in place, with a specific policy for CSE. It has also provided staff with current information about CSE. Staff understood their responsibilities in relation to child protection issues and recognised that page 15 of 35

16 concerns about possible CSE would be reported through existing child protection procedures. Inspection report Areas for improvement The service did not currently have in place a clear system for physical restraint. To date, staff had not had any occasion to use physical restraint and staff expressed an understanding that there may be a need to exercise a duty of care to safely restrain young people if they were posing a threat to their own or other people's safety or wellbeing. However, the staff team came from a variety of care backgrounds and did not share a common approach to how young people should be restrained if this was necessary. There is potential for this lack of a shared approach to result in confusion, and potentially harm, in the event that a young person needed to be safely held. The acting manager of the service advised that the preferred method was Crisis, Aggression, Limitation and Management (CALM) and an approach had been made to CALM with a view to arranging training in this method to the team. The establishment of a clear and shared approach to physical intervention should be a priority for this service (see Requirement 1). There was a need to improve some aspects of record keeping in relation to medication: - Where possible to keep a copy of the prescription on file. - To make and keep a list of staff names and signatures so that staff involved in the administration of medication can be identified. - Where young people are receiving more than one type of medication, each should be recorded on a separate sheet. - When recording medication, staff should make sure to record precisely what the medication is, how much has been given, in what dosage, and for what reason. page 16 of 35

17 (See Recommendation 1.) Although some staff had some awareness of the risks of CSE, there was need to provide all staff with specific training about this to make sure that they were aware of the risks and vulnerabilities associated with this form of abuse (see Recommendation 2). Grade 4 - Good Requirements Number of requirements In order to ensure that young people are kept safe and that their health and wellbeing is promoted, the service must establish a safe system of physical intervention which adheres to the best practice guidance Holding Safely. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011, (SSI 2011/210) Regulation 4(1)(a) - A requirement to make proper provision for the health, welfare and safety of service users. Timescale: 31 July Recommendations Number of recommendations The service should improve the system for managing medication by: - Where possible to keep a copy of the prescription on file. - To make and keep a list of staff names and signatures so that staff involved in the administration of medication can be identified. page 17 of 35

18 - Where young people are receiving more than one type of medication, each should be recorded on a separate sheet: - When recording medication, staff should make sure to record precisely what the medication is, how much has been given, in what dosage, and for what reason. National Care Standards, Care Homes for Children and Young People - Standard 12: Keeping Well - Medication 2. The service should provide all staff with training about child sexual exploitation to make sure that they are aware of the risks and vulnerabilities associated with this form of abuse. National Care Standards, Care Homes for Children and Young People - Standard 6: Feeling Safe and Secure page 18 of 35

19 Quality Theme 2: Quality of Environment Grade awarded for this theme: 4 - Good Statement 2 We make sure that the environment is safe and service users are protected. Service strengths We decided to look at this statement because it is important to check the service is providing young people with a safe and secure environment. From our discussions and observations during the inspection and from looking at a range of relevant documents, including risk assessments and records of health and safety checks, we noted the following strengths: Detailed risk assessments for the premises had been carried out and recorded. Positive risk assessments were also in place for outings and activities. These looked at individual young people's circumstances and put a plan in place which would enable them to undertake a range of activities safely, at the same time promoting their independence and a sense of responsibility. The service provider had ensured that appropriate specialised health and safety assessments had been commissioned. These included detailed assessments of potential risks to do with asbestos and legionella bacteria. In the case of the asbestos assessment, the service had restricted the use of parts of the premises until the report indicated that there were no risks detected. The house was clean, smoke free and in a good state of repair. The service had established a system of regular health and safety checks which helped to ensure that appropriate standards of safety and hygiene were maintained. page 19 of 35

20 Most staff had training in respect of health and safety issues and the designated health and safety manager had additional training to support her role. The service had a clear policy on checking young people's rooms if they suspected that prohibited substances were being used or stored. They had used this policy to good effect to promote the safety and wellbeing of young people in the house. Areas for improvement On inspection, we noted that the garage door was heavy and difficult to open fully. We suggested that this should be included in the premises risk assessment. We noted some dry food items (cereal, bread) stored uncovered in the pantry area. These should be stored in containers to avoid attracting insects or vermin. We noted that some points which had been identified for action as the result of the legionella assessment had not yet been actioned. The service provider should make sure that these issues are addressed in order to minimise the risk of waterborne infection (see Recommendation 1). Grade 4 - Good Number of requirements - 0 Recommendations Number of recommendations The service provider should ensure that prompt action is taken to address the issues identified in the recent legionella assessment. National Care Standards, Care Homes for Children and Young People - Standard 6: Feeling Safe and Secure page 20 of 35

21 Statement 3 The environment allows service users to have as positive a quality of life as possible. Service strengths We decided to look at this statement as it allows us to consider how well the environment is suited to meeting the needs of young people. From our discussions and observations during the inspection, we found that Adalia Wood provided a good standard of accommodation. We noted the following strengths: The house is spacious, light and warm. It was clean and hygienic throughout. Furnishings were good quality and comfortable. Young people liked their rooms and took a pride in looking after them. There were good facilities for the age group, that is 12 years plus. As well as TV and a computer, there was a well equipped games room in the garage, with pool table, table football and a range of fitness equipment. There was Wi-Fi access. As well as a large comfortable living room, there was also a small annexe which provided a quiet space which could be used for meetings, family visits or just for relaxing. There was extensive outdoor space which provided room for games (football goals had been ordered) and a generally pleasant rural outlook. Despite the rural location, however, young people were supported to make very good use of local facilities, particularly the gym, swimming and other sports facilities. While staff were happy to transport young people where necessary, they also encouraged them to cycle and make use of public transport. This contributed to their health and fitness and helped them to be responsible and independent. Areas for improvement We noted a few minor areas for improvement: page 21 of 35

22 - To make sure curtains were hung properly throughout the house. - To provide a blind for privacy in the downstairs bathroom. - To tidy the garden by weeding and grass cutting. Overall, though, we found that this was a pleasant and comfortable environment which met the needs of young people. Grade 4 - Good Number of requirements - 0 Number of recommendations - 0 page 22 of 35

23 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 2 - Weak 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 decided to look at this statement as it is important for us to check that staff have been recruited safely in line with current best practice in a way which safeguards young people. From our discussions with managers and staff and from looking at records of staff recruitment, we noted the following strengths: The service asked people to apply for vacancies using an application form. Staff were asked to provide evidence of identity, qualifications and registration with professional bodies. Staff were interviewed and interview notes had been made and kept. References were required and Protection of Vulnerable Groups (PVG) Scheme checks were carried out. A structured induction was in place and staff were able to do shadow shifts before assuming full shift responsibilities. Areas for improvement We found that the service had not rigorously implemented safe recruitment procedures and that it needed to make substantial improvements in the way page 23 of 35

24 that it did this to safeguard young people. It should take immediate action to ensure that: - All staff have a PVG check prior to starting work with young people. We noted that, in some cases, PVG checks had not been done until after the person had started working in the service. - The service provider should seek a minimum of two references for each person prior to appointment. In some cases we found only one reference and in some cases references had only been sent for after the person had started working in the service. - The service provider must properly check professional registers, particularly the Scottish Social Services Council (SSSC), prior to the person starting work in the service. It is not sufficient to ask for and retain a copy of that person's registration certificate. (See Requirement 1.) Grade 2 - Weak Requirements Number of requirements - 1 Inspection report 1. In order to provide a service which safeguards children and young people, the service must implement robust safe recruitment procedures by: - Making sure that all staff have a PVG check prior to starting work with young people. - Seeking a minimum of two references for each person prior to appointment, one of which should be from the current or most recent employer. - Checking professional registers (particularly the SSSC) prior to the person starting work in the service. It is not sufficient to ask for and retain a copy of that person's registration certificate. page 24 of 35

25 This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011, (SSI 2011/210) Regulation 9 - Fitness of Staff. Timescale: 30 June Number of recommendations - 0 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths We decided to look at this statement as the deployment of a professional, well trained and highly motivated workforce is of central importance to the provision of high quality care and support for young people. From our discussions with young people and staff, from our observations during the inspection and from looking at records related to staffing, we noted the following strengths: Staff were positive, welcoming and open in discussion of their work. They had worked effectively as individuals, as a team and in partnership with families and partner agencies to support young people to make positive progress within Adalia Wood. Young people reported positive, nurturing relationships with staff and said that they had really helped them to make progress. The staff team had access to some best practice guidance. For example, in relation to promoting healthy eating, CSE and Holding Safely. They had a good page 25 of 35

26 understanding of working in an outcome-focussed way and had structured care plans around the SHANARRI wellbeing indicators. Staff had done a good range of online training and most staff had done child protection training with Fife Council, the host authority. The acting manager had helped them to set up individual training folders in line with SSSC expectations and some forward planning was being done as a result of recent supervision sessions. Areas for improvement Not all staff were appropriately registered with the SSSC and not all had yet made applications to do so. The service provider did not have robust systems in place for checking and monitoring staff registration (see Quality Theme 3 - Statement 2, Requirement 1). Due to a lack of clear lines of accountability within the service, a system of supervision had not yet been established within the service. This meant that not all staff had opportunities to discuss professional and practice issues or to plan training and development opportunities (see Recommendation 1). Staff meetings had been held infrequently and had not been well attended. There had been some challenges for the team in establishing clear lines of communication and consistency which needs to be addressed as a matter of priority in order to ensure that the team could develop a consistent approach to caring for young people and for communicating with outside agencies. The acting manager had now put in place a regular team meeting structure (see Recommendation 2). There was as yet no staff development plan in place (see Recommendation 3). page 26 of 35

27 Grade 2 - Weak Number of requirements - 0 Recommendations Number of recommendations The service should ensure that all staff have the opportunity to discuss their practice at regular one-to-one supervision sessions. National Care Standards, Care Homes for Children and Young People - Standard 7: Management and Staffing 2. The service should ensure that staff meet regularly to discuss policy and practice issues and to develop consistent approaches to caring for young people. National Care Standards, Care Homes for Children and Young People - Standard 7: Management and Staffing 3. The service should develop a staff training and development plan which specifies what training staff should have and the timescales within which this should take place. National Care Standards, Care Homes for Children and Young People - Standard 7: Management and Staffing page 27 of 35

28 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 2 - Weak Statement 2 We involve our workforce in determining the direction and future objectives of the service. Service strengths We decided to look at this statement as it allows us to look at the extent to which staff skills are used to enhance the development of the service. From our discussions with staff and from looking at documents, including team meeting notes, we noted the following strengths: This was a relatively new team which had faced some challenges in getting established, including the recent absence of their manager and some very recent appointments to the team. However, we did find that staff had made some positive contributions to the development of the team, including: - Involvement in the self assessment process. - Taking on the key worker role and actively following through on tasks directly related to young people's progress within the service. - Taking on responsibility for areas of service operation, including heath and safety issues, and the development of the care plan structure. - Taking on responsibility for supporting/mentoring new staff into the service. page 28 of 35

29 Areas for improvement As noted, the team was at an early stage of development and still needed to establish regular and productive team meetings to allow them to establish a coherent approach to service development. In response to this inspection, it would be a positive move to involve the whole staff team in the development of a service improvement plan. Grade 3 - Adequate Number of requirements - 0 Number of recommendations - 0 Inspection report 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 decided to look at this statement because the establishment of robust quality assurance systems is an essential component of the establishment and maintenance of a high quality service. From our discussions with managers and staff, from looking at relevant documents during the inspection and taking into account the findings of a recent complaint investigation, we found that the service had yet to establish a quality assurance system which could support best practice and on this basis we have graded this statement as weak. We noted the following strengths: The acting manager has begun to establish a structured approach to seeking feedback from staff, parents and other stakeholders to build up a picture of service strengths and where it needs to improve. Initial responses suggest a positive experience of the service, though the information to date is necessarily limited due to the small numbers of young people to whom the service has been provided. page 29 of 35

30 The service has referred positively to external organisations, including the Care Inspectorate and the SSSC to help it to manage quality issues within the service. There are some good internal systems in place for monitoring health and safety issues and medication checks. In view of the challenges in establishing a strong management team, the service provider has engaged the services of an external consultant to support the service to address the management issues and to provide professional supervision and support for the acting manager. It was positive to note that the service had recognised the need for a structured approach to improving management arrangements in the service. Areas for improvement The service provider must take prompt action to address the following issues to ensure that the service is properly managed and that the quality of the service is evaluated and subject to continuous improvement: The service, at present, has no clear management structure. The service provider is made up of three directors, one of whom is the registered manager of the service. This person was currently suspended from their duties. One of the other directors is described as a 'sleeping partner' and manages the finances and business but takes no other part in the operation of the service. The third director is nominally a depute manager but essentially works as a residential childcare worker. She is not currently registered with the SSSC. There have clearly been trust/communication issues amongst the service providers which do not yet appear to have been resolved (see Recommendation 1). At present, there is no functional external management structure which has any kind of oversight of the quality of the service. There is limited awareness of the need for this kind of governance in anyone other than the acting manager (see Recommendation 2). page 30 of 35

31 The service should establish a comprehensive quality assurance system to make sure that key tasks are carried out on a regular basis. This should include the management oversight of incidents, health and safety checks, care plan audits, and medication audits. The use of a quality assurance calendar can be helpful in establishing this (see Requirement 1). There is a lack of clarity about what constitutes a complaint (from staff) and what constitutes a grievance. Both policies should be reviewed so that staff are clear about how to raise issues of concern within the service (see Recommendation 3). The complaints policy for young people suggests that only written complaints will receive a written response. It is good practice for any complaint to be taken seriously and a formal response offered. The complaints policy and procedure should be amended to reflect this (see Recommendation 4). Grade 2 - Weak Requirements Number of requirements In order to ensure that the service is provided to a high standard which meets the health, safety and welfare needs of service users, a comprehensive quality assurance structure should be put in place. This should include the management oversight of incidents, health and safety checks, care plan audits, and medication audits. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011, (SSI 2011/210) Regulation 4(1)(a) - A requirement to make proper provision for the health, welfare and safety of service users. Timescale: 31 July Inspection report page 31 of 35

32 Recommendations Number of recommendations The service should clarify the staffing structure, establishing clear lines of authority and accountability. National Care Standards, Care Homes for Children and Young People - Standard 7: Management and Staffing 2. The service should clarify the external management structure and define its role and responsibility in relation to monitoring the quality and performance of the service. National Care Standards, Care Homes for Children and Young People - Standard 7: Management and Staffing 3. The service should review both its complaints policy and its grievance policy and ensure that staff have a clear understanding about how to raise issues of concern within the service. National Care Standards, Care Homes for Children and Young People - Standard 7: Management and Staffing 4. The service should revise the complaints procedure to make it clear that complaints will be recorded and responded to within defined timescales. National Care Standards, Care Homes for Children and Young People - Standard 18: Concerns, Comments and Complaints page 32 of 35

33 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 Previous recommendations There are no outstanding recommendations. 6 Complaints The Care Inspectorate received a complaint in April 2016, prior to this inspection. The complaint was upheld. Details of the complaint can be found on the Care Inspectorate website At the time of this inspection, the service had made good progress towards addressing the issues raised by the complaint. 7 Enforcements We have taken no enforcement action against this care service since the last inspection. page 33 of 35

34 8 Additional Information There is no additional information. Inspection report 9 Inspection and grading history This service does not have any prior inspection history or grades. page 34 of 35

35 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 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 c?nain eile ma nithear iarrtas. page 35 of 35