Care service inspection report

Transcription

1 Care service inspection report Full inspection Lanarkshire Care Partners Housing Support Service Calder House South Caldeen Road Coatbridge Inspection completed on 05 June 2015

2 Service provided by: Lanarkshire Care Partners 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 27

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 5 Quality of staffing 5 Quality of management and leadership 4 Very Good Very Good Good What the service does well The service works very well indeed in terms of involving service users, their family members and the support staff in assessing and improving the quality of the service provided. Those we spoke with commented very favourably about the quality of the service delivered to them in a flexible yet consistent manner. The service has also made improvements to safer recruitment practices. We have commented on this further in statement 3.2 of this inspection report. What the service could do better Further improvement and development is required around how the care and support to people is planned and reviewed, including that of the associated risks to people and how these risks can be effectively managed and reviewed. We have commented on this further within statement 1.3 of this inspection report. page 3 of 27

4 What the service has done since the last inspection Inspection report The service has developed an improved management structure which not only supports the support staff more but also their oversight on how the care and support is delivered to people. Conclusion The service has worked well to meet or work towards meeting the requirements and recommendations we made at our last inspection. There are however areas for further improvement and development which we have commented on throughout this report. page 4 of 27

5 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 This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April Requirements and recommendations If we are concerned about some aspect of a service, or think it needs to do more to improve, 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 based on best practice or the National Care Standards. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reform (Scotland) Act 2010 ("the Act") and secondary legislation made under the Act, or a condition of registration. Where there are breaches of Regulations, Orders or conditions, a requirement may be made. Requirements are legally enforceable at the discretion of the Care Inspectorate. About the service we inspected Lanarkshire Care Partners aim to provide tailor-made care packages to suit the needs and requirements of the individual. They aim to provide flexible support throughout different times of the day or night and, where requested, will support people to go on holidays and short breaks. They aim to support people to engage in a range of activities of their choice based on their identified needs. At the time of this inspection the provider was the sole employee and the service was supported by one volunteer. The service was engaged in providing a range of support to 20 individuals. 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 page 5 of 27

6 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 5 - Very Good Quality of staffing - Grade 5 - Very Good Quality of management and leadership - Grade 4 - 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 or by calling us on or visiting one of our offices. page 6 of 27

7 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 this report following an unannounced inspection. The inspection took place on Monday the 25th of May when we visited the office of the service and met with staff and some service users. We returned on the 5th of June to take advantage of meeting with more service users and support staff. We gave feedback to the manager and other senior staff on Wednesday the 10th of June As part of this inspection, we took account of the completed annual return and self-assessment forms that we asked the provider to complete and submit to us. We sent 60 care standards questionnaires to the manager to distribute to service users, relatives and carers. 16 service users / carers sent us completed questionnaires. We also asked the manager to give out 30 questionnaires to staff and we received seven completed questionnaires. During this inspection process, we gathered evidence from various sources, including the following: We spoke with: - The registered service manager. - The director of Lanarkshire Care Partners. - The training officer. - One team leader - Five support workers. page 7 of 27

8 - Four service users We looked at: - The service user participation strategy. - Minutes of service user forum meetings. - Minutes of staff meetings. - A sample care and support plans. - A sample care and support plan reviews. - A sample of incident and accident reports. - Any complaints the service had received. - Relevant quality assurance information. - Service improvement and development action plans. - Newsletters. - Collated the responses from questionnaires issued to service users, carers and relatives. 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 page 8 of 27

9 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 Inspection report page 9 of 27

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. 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. Taking the views of people using the care service into account We sent out 30 care standard questionnaires to people using the service, relatives and carers. Seven were returned to us. The views from people were largely very positive. "I like the flexibility of the service and being able to take me out and about." Taking carers' views into account "A very pro-active service. Staff are always looking for new experiences for service users. A very flexible service allowing service users and carers more freedom to choose additional activities and experiences." page 10 of 27

11 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 decided to inspect the service against this statement as we wanted to assess how the service has developed and improved following any requirements or recommendations made at our last inspection. The service has a service user participation strategy which was shared with service users and their family members, explaining how the service encourages their involvement in assessing and improving the quality of the service they receive. Since our last inspection of the service, the service has held two service user / family forum meetings. We read the minutes from these meetings held and could see clear evidence of the service asking the views of people of their experiences of using the service, the standard of care and support, staffing and the management and leadership. Following positive feedback from both service users and family members, it was decided that it would be of benefit to all concerned to split these forum meetings and have separate ones for both service users and their family members. The forum meetings are scheduled to be held every three months. page 11 of 27

12 The service has also been proactive at these forum meetings by sharing information with them about the process of Self Directed Support, an option available to people which governs how they would like their support to be planned, delivered and paid for. In addition to the forum meetings, a SDS booklet has also been introduced by the service to provide further information as to the choice people have over their decision-making. On an annual basis, service users and family members are asked to complete a service satisfaction questionnaire, which again includes questions around the quality of the service, the staffing, the management and any suggestions on how the service can be improved. We looked at a sample of the responses from these questionnaires, and also the family telephone interviews to asses if people are happy with the service they receive from LCP. The comments from people were very positive and included the following: "LCP are always open to new suggestions, they respond immediately to any requests". "(A) support needs are taken into account at all times. His care needs are met 100%, so glad he is with LCP." "Having had several care companies being involved with our family, we have to say LCP are without doubt the best. All of our daughters needs are met and each of the staff members get on fantastically well with her and the rest of our family. Our team leader is available anytime to sort any problems we may have, as are the managers...we are extremely happy with the service." "B and myself are extremely happy with the care he receives from LCP." Based on the evidence seen discussions with people and the completion of our pre-inspection questionnaires, we assessed and concluded that people were page 12 of 27

13 very happy with the quality of the service provided to them. Since our last inspection, the service has also designed and introduced a new website. This resource allows both service users and potential future uses to read information about the service, learn who the managers are and see the many positive comments, testimonials left by people. It also included a day in the life of a service user, allowing them to share their experiences of using the service. Feedback is given to people following their participation in assessing and improving the quality of the service via the forum meetings or the monthly newsletter which is also shared on the website. Information is shared with people about how they can make a complaint to either the service or the Care Inspectorate. No complaints have been received since our last inspection. Many thank you cards have been left by service users and carers over the past year or so, thanking the staff and the management of the service they have received. A number of service users also volunteer in the office to undertake a variety of tasks which support the service. Areas for improvement The service was in the process of re-designing a more user-friendly service information leaflet to give to people and other stakeholders. We will follow this up at our next inspection of the service. page 13 of 27

14 Grade 5 - Very Good Number of requirements - 0 Number of recommendations - 0 Requirements 1. The service provider must ensure their policies and procedures are reviewed to reflect current legislation. Also to ensure all support staff are familiar in the use of these documents. This is in order to comply with SSI 2011/210 Regulation 4 - Welfare of users. Timescale: Seven days on receipt of this inspection report. 2. The service provider must ensure that risk assessments are undertaken to identify, support and manage the associated risks and make proper provision for the health, welfare and safety of all service users. This is in order to comply with SSI 2011/210 Regulation 4 - Welfare of users. Timescale: Fourteen days on receipt of this inspection report. Recommendations 1. The service provider should implement and maintain an accident and incident register. National Care Standards, Care at home, Standard 4 - Management and staffing. 2. The service provider should ensure that the outcomes detailed in service users support plans are individualised and person centred to meet their needs. page 14 of 27

15 National Care Standards, Care at home, Standard 3 - Your personal plan. page 15 of 27

16 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 Statement 1.1 has been taken into account for this statement. We heard from the people we spoke with that the service recruits support staff tailored to the individual needs of the service user. This ensures that the person being supported has similar interests to the staff member and supports the process of maximising the opportunity for a positive working relationship to be formed and for the support to the person be delivered in a consistent manner. We also saw examples and heard from people on how service users have been directly involved in the recruitment of staff, both at the interview stage and the staff members induction, sharing their experiences of using the service. In addition, regular discussions are held between service users and the team leaders over the suitability and performance of the support staff and meeting their ongoing care and support needs. We therefore assessed and concluded that the service had very good opportunities for people to be involved in assessing and improving the quality of the staffing within the service. Areas for improvement Statement 1.1 has been taken into account for this statement. The service could perhaps expand on the opportunities available to people by including their views in the training analysis for support staff and their annual page 16 of 27

17 appraisals which are yet to be implemented. We discussed this potential area of development with the manager who took on board our points, We will follow this up at our next inspection of the service. Grade 5 - Very Good Number of requirements - 0 Number of recommendations - 0 Requirements Inspection report 1. The service provider must ensure appropriate working and professional boundaries between staff and service users are established and maintained. This is to comply with SSI 2011/210 Regulations 3 - Services have to be provided in a way which promotes safety. 4(1)(a) - services must make proper provision for s/u welfare and safety. 9(2)(b) - employees must have the necessary skills for the work they do. This also complies to the Scottish Social Services Council codes of conduct: forming inappropriate relationships with s/us working in a safe way. Recommendations 1. The service should ensure the support and supervision meetings of staff are undertaken on a frequency which is line with their procedure. National Care Standards, Care at home, Standard 4 - Management and staffing. 2. The service should implement relevant policies, procedures and guidance for staff in relation to establishing and maintaining positive working relationships and boundaries with service users. Also focusing on the use of social media. page 17 of 27

18 National Care Standards, Care at home, Standard 4 - Management and staffing. page 18 of 27

19 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 4 - 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 Statements 1.1 and 3.1 have been taken into account for this statement. As detailed in statement 1.1 of this inspection report, the service encourages service users and their family members to complete satisfaction surveys ion a regular basis. Some of the questions asked did focus on the leadership and management of the service. In addition, the effectiveness and development of the leadership of the service is also a focus of discussions at the forum meetings held too. Areas for improvement Statements 1.1 and 3.1 have been taken into account for this statement. The service should continue to develop in this area. Grade 5 - Very Good Number of requirements - 0 Number of recommendations - 0 Statement 3 page 19 of 27

20 To encourage good quality care, we promote leadership values throughout the workforce. Service Strengths We made a requirement at our last inspection for the service to have an improved management oversight of the service through an improved management structure. This was because we had concerns at the time over the quality of the service delivered and the effectiveness of the management in making the improvements required. Since our last inspection, the service has undertaken a further management structure review and has recruited team leaders and a service trainee manager who have clear roles and responsibilities for the service provision to small groups of service users. This therefore brings a level of consistency to how the service is delivered and allows for a much improved management oversight of the service. We heard from service users, family members and indeed staff members of the added benefit of having an improved management structure in place, along with improved support to staff and communication systems. We have also commented in statement 4.4 of this inspection report of various quality assurance systems used by the team leaders, undertaking observations of work practice of the support staff they supervise. Areas for improvement The service should continue to further develop in this area. Grade 5 - Very Good Number of requirements - 0 Number of recommendations - 0 Statement 4 Inspection report page 20 of 27

21 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 Statements 1.1 and 3.1 have been taken into account for this statement; namely how the service involves service users, family members and staff in assessing and improving the quality of the service provided. We made a requirement at our last inspection for the service to make improvements as to how it continuously assesses and improves the quality of the service it delivers, through implementing various tools and processes. At this inspection, we saw some good evidence of this through the direct observations undertaken by the team leaders as to the quality of performance undertaken by the support staff. Audits are also undertaken in relation to the administration of medication and other documentation which must be completed. Areas for improvement Although there was evidence to inform us of an improvement as to how the service assesses and improves the quality of the service, we felt there was still room for further improvement. For example, a system should be introduced to assess the quality of: - How and when the care and support needs of service users are reviewed. - The quality and meaningfulness of the risk assessments completed with service users. In addition, the service did not have an improvement and development action plan or were following a recognised quality assurance framework, for example the EQFM excellence model. Having such systems in place and encouraging the involvement of service users, family members and staff in this would further strengthen how the service assesses the quality of the service. We are therefore making this a recommendation. Please see recommendation 1. page 21 of 27

22 We were made aware through our discussions with the management of the service that plans were being explored to introduce a new IT system which would support the service in terms of managing information but also to implement further quality assurance practices. We will follow this up at our next inspection of the service. The service has been pro-active in making referrals to the local authority's social work department to raise concerns around adult support and protection issues. Whilst we acknowledge that the service has followed their procedures well, the service is also required to notify the Care Inspectorate of serious incidents like this too. We are therefore making the recommendation that the service familiarise themselves with the notifications expected of the service under their registration with the Care Inspectorate. Please see recommendation 2. Grade 4 - Good Number of requirements - 0 Recommendations Number of recommendations - 2 Inspection report 1. The service provider should continue to develop their quality assurance systems to assess the quality of the service. The service could also refer to recognised quality assurance models, for example the EQFM. National Care Standards, Care at home, Standard 4 - Management and staffing. 2. The service provider should make themselves familiar with the requirement to notify the Care Inspectorate of any serious incidents referring to adult support and protection procedures, in line with our notification requirement procedures as part of their registration with the Care Inspectorate. National Care Standards, Care at home, Standard 4 - Management and staffing. page 22 of 27

23 5 What the service has done to meet any requirements we made at our last inspection Previous requirements The service provider must ensure support staff are recruited in line with current legislation and that safer recruitment practices are followed at all times. This is to comply with the Scottish Statutory Instruments (SSI) 2011 No 210, Fitness of employees. Timescale: Within twenty eight days on receipt of this report. This requirement was made on Since our last inspection of the service, the service has now implemented correct practices to ensure safe recruitment is undertaken at all times. This was clearly evidenced to us. Met - Within Timescales The service provider must ensure appropriate quality assurance systems are in place. The Regulation of Care (Requirements as to Care Services) (Scotland) Regulations 2002 SSI 2002/114 Regulation 4(1)(a) Providers shall make proper provision for the health and welfare of service users by ensuring that they have appropriate quality assurance systems in place. Timescale: Twenty eight days on receipt of this inspection report. This requirement was made on The service has implemented a variety of quality assurance measures, as detailed within statement 4.4 of this report. Met - Within Timescales page 23 of 27

24 3. 3. The Regulation of Care (Requirements as to Care Services) (Scotland) Regulations 2002 SSI 2002/114 Regulation 4(1)(a) Providers shall make proper provision for the health and welfare of service users by ensuring that they have appropriate quality assurance systems in place. This requirement was made on (As detailed above) Met - Within Timescales The service provider must ensure that staff recruited to work in a regulatory capacity within the service are recruited in accordance to safer recruitment practices. This is to comply with the Scottish Statutory Instruments (SSI) 2011, No Fitness of employees. National Care Standards, Care at home, Standard 4 - Management and staffing arrangements. This also applies to the Scottish Social Services code, (SSSC). Timescale: Immediately on receipt of this inspection report. This requirement was made on (As detailed above) Met - Within Timescales The service provider must have an effective management and leadership over the service to ensure the welfare of service users is fully met. This is to comply with the Scottish Statutory Instruments (SSI) 2011, No Welfare of service users. This requirement was made on The service has put in a new management structure. Through this change improvements have been made to the management oversight of the service. We have commented on this further in statement 4.3 of this report. Met - Within Timescales Inspection report page 24 of 27

25 6. 6. The Regulation of Care (Requirements as to Care Services) (Scotland) Regulations 2002 SSI 2002/114 Regulation 4(1)(a) Providers shall make proper provision for the health and welfare of service users by ensuring that they have appropriate quality assurance systems in place. This requirement was made on (as detailed above) Met - Within Timescales Inspection report 6 What the service has done to meet any recommendations we made at our last inspection Previous recommendations There are no outstanding recommendations. 7 Complaints No complaints have been upheld, or partially upheld, since the last inspection. 8 Enforcements We have taken no enforcement action against this care service since the last inspection. 9 Additional Information page 25 of 27

26 10 Inspection and grading history Inspection report Date Type Gradings 24 Oct 2014 Unannounced Care and support 4 - Good Environment Not Assessed Staffing 1 - Unsatisfactory Management and Leadership 2 - Weak 30 May 2014 Announced (Short Notice) Care and support Environment Staffing Management and Leadership 3 - Adequate Not Assessed 2 - Weak 2 - Weak 24 Dec 2012 Unannounced Care and support 3 - Adequate Environment Not Assessed Staffing 3 - Adequate Management and Leadership 3 - Adequate page 26 of 27

27 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 27 of 27