Brisbane Supported Accommodation Project Care Home Service Adults Brisbane House 165 Hamilton Road Mount Vernon Glasgow G32 9QT Telephone:

Transcription

1 Brisbane Supported Accommodation Project Care Home Service Adults Brisbane House 165 Hamilton Road Mount Vernon Glasgow G32 9QT Telephone: Inspected by: Scott Morrison Type of inspection: Unannounced Inspection completed on: 28 February 2013

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 6 3 The inspection 9 4 Other information 24 5 Summary of grades 25 6 Inspection and grading history 25 Service provided by: Scottish Association For Mental Health Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Scott Morrison Telephone enquiries@careinspectorate.com Brisbane Supported Accommodation Project, 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 Very Good Quality of Environment 5 Very Good Quality of Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well The service provides a safe and caring environment that helps service users on their journey to recovery through encouraging independence and community participation. Staff are supported by the provider and manger to develop their skills and knowledge - this is having a positive impact on outcomes for service users. What the service could do better The service should further consider the way it works with service users to develop care plans and risk assessments - this should lead to improved service user participation in planning and reviewing outcomes. What the service has done since the last inspection The service has made significant progress in relation to the recommendations made at the last inspection. Developments include: improved needs-led assessment; service user participation, and staff development/ training. Conclusion Brisbane Supported Accommodation continues to offer service users an environment that makes them feel safe, supported and able to work towards a more independent life. The service has evidenced a strong commitment to improving the lives of women with mental health issues through participation and community development. Brisbane Supported Accommodation Project, page 3 of 27

4 Who did this inspection Scott Morrison Brisbane Supported Accommodation Project, page 4 of 27

5 1 About the service we inspected The Brisbane Supported Accommodation Project provides a care home service for a maximum of five women with mental health problems. The Scottish Association for Mental Health (SAMH) manages the service. The service is in the East End of Glasgow and has very good transport links and access to local amenities. The Service occupies a semi-detached property with spacious garden areas to the front and rear. The Service property has two floors with a mezzanine level inbetween. Each of the service users has their own bedroom. With the exception of the bedroom on the ground floor that has an en-suite, service users share access to the bathrooms. The communal lounge and dining area and kitchen are situated on the ground floor. Internal stairs access the remaining bedrooms. The Service states that its aim is to "provide accommodation to service users assessed as requiring, at times in their daily lives, access to high levels of support. This includes physical care, personal finances and personal and household hygiene. We also aim for service users to resettle within the community". The Care Commission registered the Brisbane Supported Accommodation Project on the 1st April 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 Environment - Grade 5 - Very Good Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 5 - Very Good This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. Brisbane Supported Accommodation Project, page 5 of 27

6 2 How we inspected this service The level of inspection we carried out In this service we carried out a low intensity inspection. We carry out these inspections when we are satisfied that services are working hard to provide consistently high standards of care. What we did during the inspection We wrote the report following an unannounced inspection. The inspection was carried out by Scott Morrison over 2 days. Between 9am-5pm on the 15 and 10am-12pm on the 28 February In this inspection we gathered evidence from various sources, including the relevant sections of policies, procedures, records and other documents including: Certificate of Registration Accident log Incident log Complaints/suggestions log Medication records Quality Assurance Audits Questionnaires Care plans of people who use this service Personal Activity Plans Staff training records Staff meeting minutes Staff supervision notes Self assessment document Newsletter. Brisbane Supported Accommodation Project, page 6 of 27

7 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 Brisbane Supported Accommodation Project, page 7 of 27

8 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. The service provider told us how the people who used the care service had taken part in the self assessment process. Taking the views of people using the care service into account The views of those who use the service are incorporated onto the report. Taking carers' views into account No carers were available for comment at this inspection. Brisbane Supported Accommodation Project, page 8 of 27

9 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 During our inspection we found the service was performing very well in the areas covered by this statement. We came to this conclusion after looking at personal plans, reviewing policy/ procedures (and how these were used), talking to service users, talking to staff and managers. From this evidence we were satisfied that a number of methods were employed to encourage those who used the service to participate in assessing and improving the quality of the service. We saw an activities calendar organised until May 2013 and heard how service users had suggested and developed the activities on the calendar during their monthly service user meetings. From this, we could see how service users used their meetings to influence weekly and monthly planning within the service - this included activities, trips and holidays. Service users had copies of the activities calendar and one service user also highlighted that 'we have a board that tells us what activities are on'. Discussions with service users indicated that they were encouraged by staff to develop interests and links with the wider community: 'I go to Asda for lunch, I go myself...i'm allowed out...not at night though'; 'I go to a club on a Monday...we make things...we do exercises...i get the bus there myself'; 'I'm able to go walks myself, staff also go when it's nice'; 'I go to an arts and crafts group every Thursday'; 'I bought a mobile, I'm able to make my own calls'; 'I make my own decisions about what I do...i go to a diet club'. The provider had developed a participation strategy for and this led to the development of a 'Participation Toolkit' and framework for participation within the service. Brisbane Supported Accommodation Project, page 9 of 27

10 We saw how the service had introduced a 'Participation Co-ordinator' who was central to the development of its 'Participation Framework'. An Advocacy Service recently attended the service to independently facilitate feedback from, and participation of, service users. We read the findings report from the Advocacy Service, this clearly indicated that service users were very satisfied with the quality of the care provided. We would expect the service to develop this report and incorporate its findings into its service plan. We also saw evidence of service users being involved in Participation and Service User Forums; allowing service users to influence policy and practice within SAMH at local and national levels. The provider was able to show us how these ideas were developed and implemented - one example of this was the development of a 'Meet and Greet' event at the SAMH Head Office that had been suggested by the forum as a way of developing stronger links between service users and SAMH. The service showed us the range of service user questionnaires used to gain feedback on ways to improve participation and the service in general. The service also uses 'exit interviews' to allow service users to give their views upon moving on from the service. The service has developed a range of other ways to develop participation including quizzes, newsletters and suggestion boxes. Areas for improvement The service should continue to develop ways of seeking views from service users and facilitating community participation. In particular, it should develop ways to evidence outcomes from its participation approaches. This should focus on how participation is improving the service's ability to work with service users to achieve goals in working towards recovery and independence (see comments in 1.3 re care planning). Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Brisbane Supported Accommodation Project, page 10 of 27

11 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Inspection report continued We found that this service was performing very well in the areas covered by this statement. The service was able to evidence that it effectively met the health and wellbeing needs of people who use the service. To come to this conclusion we spoke to service users, spoke to staff and managers, sampled personal plans, reviewed records and reviewed procedures. We sampled three personal plans and found that they provided a clear and comprehensive evaluation of the health and wellbeing needs of each service user. The plans were written from a strengths based perspective - this is very good practice and helps develop a person-centred care plan. The service had also developed 'My Outcomes' assessments where service users and staff worked together to identify goals. Again, this was very good work and reflected a person-centred, holistic approach. These assessments included action plans for each aspect of a person's life. A broad range of risk assessments were evident in each care plan. There was evidence of the service reviewing these on a regular basis. However, the risk assessments we read could be more person-centred. The service should more explicitly incorporate the views of the service user when identifying and assessing risk. When considering issues of vulnerability, aggression or behaviour that present challenges, the service should further develop its assessments to record and analyse triggers and effective strategies. A previous inspection had recommended that the service 'should ensure that the system for any medication should follow up-to-date best practice guidance'. During our inspection we were satisfied with the steps taken by the service to address this through the appointment of a staff member responsible for medication and the development of robust medication policy/ procedure. It was very good to see that service users were actively involved in their medication - one service user commented 'staff make sure we take our medication and use the MARS sheet...we both sign it'. We were impressed with the developmental work staff were encouraged to undertake - one staff member commented, 'I have an interest in health...especially health checks and walking. I've been supported by my manager to do 'Paths to Health' (walking leader)...it's about developing organised walks to encourage wider links between women in the service and the wider community'. Brisbane Supported Accommodation Project, page 11 of 27

12 The service had developed a community mapping resource to inform staff and service users of local resources such as gyms, resource centres, libraries, education/ training, trusts/ charities etc. We were able to see how the service used this resource to help broaden service users links with the wider community. Service users and staff were also being encouraged to develop photographic recording of activities. The service is planning to incorporate photographic recordings into care plans and service reviews - this can be an excellent way of encouraging service users to be more involved in the planning and evaluation of their care. Service users told us about the range of activities they were encouraged to take part in. These included flower arranging, dancing & singing, karaoke, arts & crafts, attending clubs, attending college and fitness/ health classes. Feedback from service users that indicated they were very happy with the way the service addressed their health and wellbeing needs included: 'I'm more independent...doing my own washing and cooking'; 'I'm exercising...i have an exercise bike'; 'I make my own decisions about what I do...i go to a diet club'; 'I went to John Wheatley College and we are going to the Steamie'. We also heard how service users are helped to maintain appointments - 'any appointments I have, I show to staff - they put it in a book so they can support me'. Areas for improvement The strengths based approach to assessment used by the service is very good practice. However, the service should further develop care plans to explicitly identify short, medium & long term goals. Negotiating and working towards identified goals is central to meaningful partnership working between service user and service. The setting of goals also assists the planning, reviewing and evidencing of outcomes for service users. To address some of this, we would recommend that the 'My Outcomes' assessment be integrated into the care planning and review process. The service should more explicitly incorporate the views of the service user in developing risk assessments. When considering issues of vulnerability, aggression or behaviour that present challenges, the service should further develop its assessments to record and analyse triggers and effective strategies. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 2 Brisbane Supported Accommodation Project, page 12 of 27

13 Recommendations Inspection report continued 1. The service should further develop the care plans for service users to explicitly identify personalised short. medium and long term goals. This will assist service users and staff to effectively review progress and achievement of aims. (National Care Standards: Care Homes for People with Mental Health Problems; Standard 8 - Making Choices). 2. Risk assessments should be reviewed to more explicitly include the views of the service user when assessing and reviewing risk factors. (National Care Standards: Care Homes for People with Mental Health Problems; Standard 9 - Making Choices & & Standard 11 - Expressing your Views). Brisbane Supported Accommodation Project, page 13 of 27

14 Quality Theme 2: Quality of Environment 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 environment within the service. Service strengths We found that this service was performing very well in the areas covered by this statement. We concluded this after we; * Spoke with service users * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records. The strengths for the service user and carer involvement, detailed under Quality Theme 1, statement 1 are the same for this statement. In addition: We saw evidence of service user participation in a number of areas relating to the environment. The service has developed its 'welcome pack' and induction to include discussion about the requirements and suitability of living space for service users. Issues relating to the living environment were discussed at service user meetings and reviews. We saw from minutes of service user meetings that there had been consultation over the redecoration of different areas of the service. One service user we spoke to confirmed 'we all helped pick the colours the rooms should be painted'. The individual rooms that we visited were well decorated, comfortable and reflected the personalities of those living there. Feedback from service users suggested that they felt well informed and consulted in relation to their environment. We heard how the service is currently in consultation over possible plans to extend the building. Brisbane Supported Accommodation Project, page 14 of 27

15 Areas for improvement The service should continue its very good work in relation to service user involvement. It should continue to develop ways of evaluating the impact service user involvement has on service development. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Brisbane Supported Accommodation Project, page 15 of 27

16 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths We found that this service was performing very well in the areas covered by this statement. We concluded this after we: * Spoke with service users * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records. In addition: We reviewed the range of policies and procedures put in place by the provider to maintain the safety and protection of service users and staff. We were satisfied that these were appropriate and fit for purpose. Service users we spoke to were clear about how they would raise any concerns they may have - 'I speak to staff if I have any problems'. We saw evidence of service users having individual copies of the complaints procedure and these were also visible on the walls of the home. The service maintained records of all accidents, incidents and falls - we were able to see that these were clearly recorded by staff, including any actions taken. We were also satisfied that policies, procedures and recordings were quality assured by the manager of the service and also externally audited (see statement 4.4). Service users had individual risk assessments that outline areas of vulnerability. It was evident that these assessments were used by staff to make safe, informed decisions about risk factors. Areas for improvement The service should continue its very good work in this area. Please refer to the recommendation under Statement 1.3 regarding service user involvement in risk assessment. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Brisbane Supported Accommodation Project, page 16 of 27

17 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths We found that this service was performing very well in the areas covered by this statement. We concluded this after we: * Spoke with service users * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records. The strengths for the service user and carer involvement, detailed under Quality Theme 1, statement 1 are the same for this statement. In addition: We saw evidence of a strong ethos of service user participation within the Service. We could see that this participation extended to quality of staffing through a number of means including: 1) An 'open door' staff and management approach that encouraged those who use the service to discuss any issues or ideas they had about the Service 2) Monthly service user meetings 3) Implementation of a 'Service User Participation Strategy' 4) Involvement of service users in the recruitment of staff and managers - there had been no recent appointments, so we were not able to inspect the quality of service user participation 5) Advocacy Service involvement in evaluating the service and its staff 6) The incorporation of service users views into annual staff appraisals. Areas for improvement The service should continue its very good work in relation to service user involvement. It should continue to develop ways of evaluating the impact service user involvement has on service development. Brisbane Supported Accommodation Project, page 17 of 27

18 Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Brisbane Supported Accommodation Project, page 18 of 27

19 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths We found that this service was performing very well in the areas covered by this statement. We concluded this after we: * Spoke with service users * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records. In addition: We found evidence that the annual appraisal and regular staff supervision identified practice/ professional development issues and these were reviewed on an ongoing basis. Our discussion with staff indicated they felt well supported by managers within the service. All staff interviewed confirmed they received supervision every 4-6 weeks. Annual appraisals incorporated feedback from service users - this was used as the basis for areas of strength and areas for development. We could see how this process informed the development of training programmes for staff. All staff interviewed identified a broad range of training received in the past year. All staff were satisfied with their levels of training. A training programme was clearly evident for each member of staff. We were also able to see how staff were encouraged to become responsible for service development. We were particularly impressed by the staff driven developments of participation/ community involvement and medication/ health. Staff we spoke to commented that the manager 'encourages us to develop areas of interest and then present this to other staff...we all support each other'. Discussion with staff indicated that they have a clear understanding of the aims and objectives of the Service. Staff and managers have a very evident commitment to developing the Service. Staff and managers spoke enthusiastically about their Service and this commitment was reflected in the positive feedback about staff from service users. Areas for improvement Inspection report continued The Service should continue developing its training programme for staff. It would also be beneficial to strengthen its staff forum for the sharing of new knowledge and best practice learned through training - this would further encourage a culture of implementing new learning in practice. Brisbane Supported Accommodation Project, page 19 of 27

20 The service should strive to encourage staff to become more reflective practitioners e.g. encouraging the writing of reflective logs to be discussed at supervision and team meetings. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Brisbane Supported Accommodation Project, page 20 of 27

21 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths We found that this service was performing very well in the areas covered by this statement. We concluded this after we: * Spoke with service users * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records. The strengths for the service user and carer involvement, detailed under Quality Theme 1, statement 1 are the same for this statement. In addition: During our inspection, we were able to see that service users had the opportunity to influence management and leadership of the service through: * An 'open door' approach, allowing service users to readily access the manager * Monthly service user meetings * Service user satisfaction surveys * Service user involvement in recruitment of staff. We heard from one member of staff about how they had 'learned a lot about participation - what women wanted to do...i have been actively encouraged to use my skills and knowledge from my last job to develop our service'. From talking to staff and managers we could see that there was a clear sense of aims and objectives for the Service and a set of supporting policies and procedures. From what we have seen, we believe that strong leadership and management have been an important factor in driving developments within the Service. Brisbane Supported Accommodation Project, page 21 of 27

22 Areas for improvement The service should continue its very good work in relation to service user involvement. It should continue to develop ways of evaluating the impact service user involvement has on service development and leadership. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Brisbane Supported Accommodation Project, page 22 of 27

23 Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide Service strengths We found that this service was performing very well in the areas covered by this statement. We concluded this after we: * Spoke with service users * Spoke with staff and management * Looked at questionnaires * Reviewed a sample of personal plans and other records. In addition: Through talking to managers and reviewing procedures within the Service we were satisfied that there was a robust quality assurance framework being implemented. We saw evidence that an annual audit of the service was being carried out by an external manager. It was evident that the external audit produced a detailed evaluation of the service. We could also see clear evidence of how findings from the external audit were used by the service in developing its operational plan and annual review. In doing so, the audit would appear to reflect the best practice principles of social care audit as suggested by Payne (2008). The service held a central health and safety file containing all relevant policies and procedures, general risk assessments and incident/ accident logs. The service also evidenced good practice through its 'Monthly Care Home Health, Safety & Wellbeing' audit. We were also able to see how these audits fed into service user risk assessments and the service action plan. From the service user files we sampled, it was evident that regular case file audits were being completed by the service manager. Areas for improvement Where service user file audits raise action points, it was not always clear whether these had been addressed. It would be beneficial for the file audit paperwork to be amended to clearly indicate when action has been taken to resolve the issue - these should be signed and dated. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Brisbane Supported Accommodation Project, page 23 of 27

24 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 None. Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). Brisbane Supported Accommodation Project, page 24 of 27

25 5 Summary of grades Quality of Care and Support Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Environment Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Staffing Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Management and Leadership Very Good Statement 1 Statement Very Good 5 - Very Good 6 Inspection and grading history Date Type Gradings 25 Nov 2010 Unannounced Care and support 4 - Good Environment Not Assessed Staffing 4 - Good Management and Leadership Not Assessed 29 Jun 2010 Announced Care and support 4 - Good Environment 5 - Very Good Staffing 4 - Good Management and Leadership Not Assessed 25 Mar 2010 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 3 - Adequate Management and Leadership 4 - Good Brisbane Supported Accommodation Project, page 25 of 27

26 22 Jul 2009 Announced Care and support 4 - Good Environment 4 - Good Staffing 2 - Weak Management and Leadership 4 - Good 24 Mar 2009 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 13 Jun 2008 Announced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Brisbane Supported Accommodation Project, page 26 of 27

27 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: Brisbane Supported Accommodation Project, page 27 of 27