Dudhope Villa and Sister Properties Housing Support Service 1 St Mary Place, Dundee DD1 5RB Telephone:

Transcription

1 Dudhope Villa and Sister Properties Housing Support Service 1 St Mary Place, Dundee DD1 5RB Telephone: Inspected by: Karen Penman Type of inspection: Announced (Short Notice) Inspection completed on: 20 September 2013

2 Contents Page No Summary 3 1 About the service we inspected 4 2 How we inspected this service 5 3 The inspection 10 4 Other information 23 5 Summary of grades 24 6 Inspection and grading history 24 Service provided by: Dudhope Villa and Sister Properties Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Karen Penman Telephone enquiries@careinspectorate.com Dudhope Villa and Sister Properties, page 2 of 25

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 Good Quality of Staffing 4 Good Quality of Management and Leadership 4 Good What the service does well The service provides care and support for vulnerable adults living in Dundee. The staff group support people to access appropriate medical advice which helps to improve and maintain their health and wellbeing. What the service could do better The service should review its policies and procedures to ensure that they are reflective of current best practice and legislation. What the service has done since the last inspection The service has developed a procedure for managing peoples finances. Conclusion The service provides care and support for vulnerable people living in Dundee. The staff group work with a wide range of professionals to ensure that people are supported to manage their own health and wellbeing. Who did this inspection Karen Penman Lay assessor: Not Applicable. Dudhope Villa and Sister Properties, page 3 of 25

4 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 This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April Dudhope Villa and Sister Properties is registered by the Care Inspectorate to provide a combined Care at Home and Housing Support Service. The service is for adults with special needs. The service aims to meet the needs of individuals for personal care, personal support needs, general counselling, advice and guidance. The service works with other agencies to meet needs. Service users can choose to have an alternative Care at Home Provider is they so wish. The service provides accommodation on a full board basis at Dudhope Villa and in nine flats at other addresses in the city of Dundee. The service is provided by a manager and a team of eleven staff, including support workers and domestic staff. The service is provided on a 24 hour basis, with a constant staff presence in Dudhope Villa and planned visiting support and on- call support to the nine flats. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 4 - Good Quality of Staffing - Grade 4 - 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. Dudhope Villa and Sister Properties, page 4 of 25

5 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 This report was compiled following a short notice announced inspection. The inspection was carried out by Inspector Karen Penman on 17 September and 19 September Feedback was given to the Manager, Assistant manager and Dundee City Council Contracts Officer on Friday 20 September During this inspection we gathered evidence from a variety of sources which included; - evidence from the service's most recent self assessment - personal plans of people who used the service - training records - accident and incident records - serious incident records - questionnaires that had been completed and returned to the Care inspectorate prior to inspection - stakeholders questionnaires - contact notes - medication records We also had discussions with; - the manager and assistant manager - we spoke to and observed support staff - the people who used the service - a care manager 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 Dudhope Villa and Sister Properties, page 5 of 25

6 Inspection Focus Areas (IFAs) Inspection report continued 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 Dudhope Villa and Sister Properties, page 6 of 25

7 What the service has done to meet any requirements we made at our last inspection The requirement The provider must use its safer recruitment procedures for all staff who work in the service, whether paid or unpaid, to ensure that only people fit to be working with service users are employed to do so. This is in order to comply with SSI 2011/210, regulation 9. This is a requirement for providers not to employ staff unless they are fit to be employed. Timescale for completion - Immediate upon receipt of this report. What the service did to meet the requirement Not met. This requirement has been restated under Statement 3.3 The requirement is: Not Met The requirement The service provider must keep the funds of the service separate from personal funds held on behalf of service users and have a record of regular audits of the funds held for service users.the Social Care and Social Work Improvement Scotland (Registration) Regulations 2011 (SSI 2011/28) regulation 4(1)(a). This is a requirement for providers to keep records as notified by the Care Inspectorate. Timescale for completion - two weeks following receipt of this report. Dudhope Villa and Sister Properties, page 7 of 25

8 What the service did to meet the requirement The service has developed a procedure for managing peoples finances and carries out regular audits. The requirement is: Met - Within Timescales The requirement The service provider must ensure that all notifiable incidents are reported to the Care Inspectorate as per the guidance ' Records all services ( excl CM's) must keep and notification reporting guidance.this is in order to comply with SSI 2011/210 Regulation 4 (1) (a) Timescale for completion - Immediate upon receipt of this report. What the service did to meet the requirement The service was aware of their responsibility to notify the Care Inspectorate as per guidance. The requirement is: Met - Within Timescales The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self-assessment document from the provider. We were satisfied with the way the provider completed this and with the relevant information included for each heading that we grade services under. The provider identified what it thought the service did well, some areas for improvement and any changes it had planned. Dudhope Villa and Sister Properties, page 8 of 25

9 Taking the views of people using the care service into account We spoke with people who lived in Dudhope Villa during our inspection and visited with others in the sister properties. People told us that they were happy with the care and support that the service provided. They told us that the staff had helped them manage their health and that they felt better and looked better as a result. We received 22 completed care standard questionnaires prior to the inspection. Some of the comments within these included; 'I am happy here' 'They (staff) make sure I am safe and well' 'I like that everyone knows my name' 'The staff listen to me when I have something to say' Taking carers' views into account There were no carers present during this inspection. Dudhope Villa and Sister Properties, page 9 of 25

10 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 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 considered a range of evidence presented in relation to this statement. We thought that the service was performing at a very good level. Some of the strengths we saw were; 'House Meetings' were held in the villa and in each of the sister properties around Dundee. These were generally well attended by people who used the service. We saw discussions had taken place about menus, staff changes - people were informed of staff who were leaving the service and new staff who had joined the team. There was detailed information about holiday planning and feedback given when people had returned. This information helped people to express their preferences and make choices about what food they would like on the menu and where they wanted to go for future holidays. A menu had been devised using the comments received from people who used the service and the manager or the designated cook for the day checked what people would like on a daily basis. People who used the service told us that the staff team knew what food they liked and didn't like and always made sure that they were catered for. Dudhope Villa and Sister Properties, page 10 of 25

11 People who used the service had personal plans and these were reviewed and rewritten every six months. We could see in the minutes of these reviews that people who used the service had been involved in the discussions and where they had requested changes that these had been explored and agreed where appropriate. Daily contact records were kept by staff and provided a good level of detail of discussions with people who used the service and any issues raised and how these were dealt with. The service had introduced a stakeholders questionnaire earlier this year which asked people their views on the service. This gave people the opportunity to make suggestions for improvements to the service. People who used the service told us that they had regular discussions about outings and activities. Planned activities were visible on a noticeboard in the villa. People who used the service had been involved in choosing photographs to display in the villa to show people what sort of activities they had enjoyed. Areas for improvement House meetings provided an opportunity for people who used the service to participate in assessing and developing the service. Recent minutes of these meetings provided clear detail about the discussions that were held and also gave information about progress on plans or a follow up to any issues raised. The service should continue to arrange these meetings as a method of involving people in wider aspects of developing the service. We discussed with the management team how the stakeholder questionnaire could be developed to obtain feedback from people about specific areas of the service as the service continues to develop. Although we could see that the service was reviewing the personal plans every six months, it wasn't always clear who had been involved in the review and how outcomes had been agreed. The service should develop their recording format to make this clearer. (Recommendation 1) Dudhope Villa and Sister Properties, page 11 of 25

12 Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service should ensure that an accurate record of reviews of personal plans that reflects how people who used the service were involved. National Care Standards - Care at Home - Standard 3 - Your personal plan. Dudhope Villa and Sister Properties, page 12 of 25

13 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths We considered a range of evidence presented in relation to this statement. We thought the service was performing at an adequate level. Some if the strengths we saw were; Inspection report continued People who used the service had a personal plan. This provided staff with basic knowledge of what care and support people needed to keep well. Some people had started to develop life plans. This was in the early stages but we felt that this was a good development which helped people think about their dreams and aspirations as well as the risks associated to their plans for the future. The service had accessed training and support from the Dietetics service and had implemented the MUST tool and were recording peoples weights regularly. We could see that appropriate action had been taken when concerns had been raised. People who used the service were supported to attend hospital and GP appointments and were encouraged to attend their GP surgery for annual health checks. This helped to support people to access appropriate support to maintain and improve their health. The service works with range of professionals including Community Nurses, Care Managers and enablement groups. The service took responsibility for ordering and storing medication. People who used the service had signed agreements that they were happy with this arrangement. This was arranged with the aim of ensuring that people took their medication as prescribed to maintain their health and wellbeing. Staff had completed a range of appropriate training including medication training and fire awareness. Further training in First Aid was planned for the near future. The management team informed us that they had also received support from the Community Nurses to inform their training. This helped to ensure that staff had access to opportunities that would help them develop their skills and knowledge when supporting people who used the service. There were a range of activities and outings arranged that people could participate in. People we spoke to during the inspection told us how they enjoyed the holidays in the past and that they were looking forward to going to Blackpool in October. Dudhope Villa and Sister Properties, page 13 of 25

14 Areas for improvement Inspection report continued Personal plans held basic information about peoples care and support needs. In some examples, we felt that the information should be developed further to reflect the range of care and support that the service was providing specific to peoples needs. We viewed a record of an allegation made by someone who used the service. The allegation was not referred to the Adult protection team for further consideration. The service should ensure that there is a clear protocol for dealing with allegations of abuse and a record maintained of actions and outcomes that adheres to Adult Support and Protection procedures. We discussed this during our inspection and have made a requirement in relation to this. (Requirement 1) The service took responsibility for ordering and storing peoples medication. People who used the service had signed a medication agreement consenting to this. We had concerns about how staff were dispensing medication and recording medication as administered. We felt that the procedure increased the risk of errors and identified occasions when people had not taken their medication. We discussed how the service should review their current procedure to ensure that there are individualised assessments of the support that people require to manage their medication. We gave the management team the Care Inspectorate publication 'Guidance about medication personal plans, review, monitoring and record keeping in residential care services' and referred them to The Royal Pharmaceutical Society publication 'The handling of medicines in social care' which could support them in a review of their policy and procedures. We have made a requirement in relation to this. (Requirement 2) The service supports people with a range of complex needs. The management have identified the need to source training in challenging behaviour, de-escalation and restraint. We have made a requirement in relation to this. (Requirement 3) We made a recommendation at our previous inspection in relation to the language used by staff with the support plans. We saw that there were comments describing people as 'lazy' and 'making a nuisance' of themselves. We have restated the recommendation that staff should use language that is respectful... (Recommendation 1) Dudhope Villa and Sister Properties, page 14 of 25

15 Grade awarded for this statement: 3 - Adequate Number of requirements: 3 Number of recommendations: 1 Requirements 1. The provider must review its medication procedures to ensure that they are reflective of best practice guidance and current legislation. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 SSI 2011/210 regulation 4(1)(a). Timescale :- within 1 month of receipt of this report. 2. The provider must ensure that staff have the appropriate skills and knowledge in relation to challenging behaviour and restraint practices. This is in order to comply with The Social Care and SOcial Work Improvement Scotland (Requirements for Care Services) Regulations 2011 SSI 2011/210 Regulation 4(1)(c) Timescale:- within 3 months of receipt of this report. 3. The provider must ensure that it has clear protocols that adhere to Adult Support and Protection procedures. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 SSI 2011/210 Regulation 4(1)(a) Timescale:- Immediate upon receipt of this report. Recommendations 1. The service should ensure that when writing in personal plans, staff use language that is respectful to people who use the service. National Care Standards - Housing Support Services - Standard 3 - Management and Staffing arrangements. Dudhope Villa and Sister Properties, page 15 of 25

16 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 4 - Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths Information reported under Theme 1 Statement 1 was considered in relation to this statement. Areas for improvement As reported under Theme 1 Statement 1. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Dudhope Villa and Sister Properties, page 16 of 25

17 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths We examined a range of evidence in relation to this statement. We thought that the service was performing at a good level. Some of the strengths we saw were; Inspection report continued Staff meetings were held regularly and were well attended by the staff team. The staff used this opportunity to discuss the care and support that they were providing for people who used the service. This helped to ensure a consistent approach was maintained when working with people who used the service. The management team held monthly meetings where they had a more in depth discussion about care and support provided by the staff team as well as the development of the service. Staff had supervision regularly. Regular agenda items included reflection on work plans, professional development and information sharing. This gave staff the opportunity to consider their own work practice and their needs for self development. A range of training had been completed and the management team had identified that it needed to review training needs with the staff team. We thought that this would be a positive development and discussed the need to include regular moving and handling training, adult support and protection, challenging behaviour and restraint. Staff appeared motivated and enthusiastic about their jobs. We observed staff to be patient, respectful and encouraging when interacting with people who used the service. Dudhope Villa and Sister Properties, page 17 of 25

18 Areas for improvement The management team had identified a need to review the training needs of the staff team to reflect the range skills that the staff team would need to support the range of complex needs that people who used the service had. We made a recommendation at our previous inspection which we have restated here. (Recommendation 1) The service stated in their own policies that staff would have annual appraisals. This had lapsed in recent years and we discussed the benefits of reinstating this process to support staff development. (Recommendation 2) We made a requirement at our previous inspection regarding safer recruitment procedures. Although this had been resolved, we were made aware that a member of staff had returned to the service following a short period in other employment. The service had not checked the PVG scheme due to the very short time since the last PVG had been completed. The provider should ensure that it follows robust safer recruitment procedures for all staff working in the service and therefore the requirement is restated. (Requirement 1) Grade awarded for this statement: 4 - Good Number of requirements: 1 Number of recommendations: 2 Requirements 1. The provider must use its safer recruitment procedures for all staff who work in the service, whether paid or unpaid, to ensure that only people fit to be working with service users are employed to do so. this is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 SSI 2011/210 regulation 9 (1). Timescale for completion - immediate upon receipt of this report. Recommendations 1. The service should seek to enhance the training programme for staff. This would allow for staff to further expand their skills and knowledge when supporting a very complex group of people. National Care Standards - Housing Support Services - Standard 3 - Management and Staffing arrangements. Dudhope Villa and Sister Properties, page 18 of 25

19 2. The service should continue with its plans to recommence annual appraisals for staff as detailed within their own policies for staff support. National Care Standards - Housing Support Services - Standard 3 Management and Staffing arrangements. Dudhope Villa and Sister Properties, page 19 of 25

20 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 The evidence reported under Theme 1, Statement 1 was also considered in relation to this statement. Areas for improvement As reported under Theme 1 Statement 1. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Dudhope Villa and Sister Properties, page 20 of 25

21 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 The management team carried out a range of regular audits to help them assess the quality of the service they provided. These audits included; - Environmental audits - these were carried out in each of the properties that people who used the service were living. We could see that issues raised by people were recorded and the action and resolution was also detailed. This helped to ensure that people were happy with their living arrangements. - Medication audits - this identified that all signatures were entered on the MARS sheets. - Care plan audits Inspection report continued There was a range of policies and procedures which were discussed with staff and staff then signed to acknowledge this. Staff meetings gave the staff team the opportunity to discuss the service that they were providing. Reviews of care and support were held regularly with people who used the service, relevant professionals and family members. This gave people the opportunity to discuss the service that they received and to make suggestions for changes and improvements. House meetings were held in each of the properties and minutes taken that reflect comments from people who live there and improvements that they felt would improve the service for them. We could see that their suggestions had been considered and appropriate action taken where appropriate. This helped people who used the service to express their views about the quality of the service. Stakeholder questionnaires had been developed and sent out earlier this year. This gave people the opportunity to comment on various aspects of the service. For example communication with staff and how the service was performing in relation to National Care Standards. Dudhope Villa and Sister Properties, page 21 of 25

22 Areas for improvement We had concerns regarding the recording of medication processes on the MARS sheet and have made a requirement regarding this. (See 1.3) Policies and procedures require to be updated to reflect best practice and current legislation. The management team were aware of this and were planning to review their policies and procedures. (recommendation 1) Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service should review its policies and procedures to ensure that they are reflective of current best practice guidance and legislation. National Care Standards - Care at Home - Standard 4 Management and Staffing. Dudhope Villa and Sister Properties, page 22 of 25

23 4 Other information Complaints No complaints have been upheld, or partially upheld, since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information No additional information noted. 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 the Care Inspectorate re-grading a Quality Statement within the Quality of Management and Leadership Theme (or for childminders, Quality of Staffing Theme) as unsatisfactory (1). This will result in the Quality Theme being re-graded as unsatisfactory (1). Dudhope Villa and Sister Properties, page 23 of 25

24 5 Summary of grades Quality of Care and Support Good Statement 1 Statement Very Good 3 - Adequate Quality of Staffing Good Statement 1 Statement Very Good 4 - Good Quality of Management and Leadership Good Statement 1 Statement Very Good 4 - Good 6 Inspection and grading history Date Type Gradings 23 Nov 2012 Announced (Short Notice) Care and support Staffing Management and Leadership 5 - Very Good 4 - Good 4 - Good 2 Mar 2012 Announced (Short Notice) Care and support Staffing Management and Leadership 4 - Good Not Assessed 4 - Good 12 May 2010 Announced Care and support 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 5 May 2009 Announced Care and support 4 - Good Staffing 3 - Adequate Management and Leadership 3 - Adequate All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Dudhope Villa and Sister Properties, page 24 of 25

25 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 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: or by telephoning Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: enquiries@careinspectorate.com Web: Dudhope Villa and Sister Properties, page 25 of 25