Kempsthorn Crescent Care Home Service Children and Young People 40 Kempsthorn Crescent Pollok Glasgow G53 5SU Telephone:

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1 Kempsthorn Crescent Care Home Service Children and Young People 40 Kempsthorn Crescent Pollok Glasgow G53 5SU Telephone: Inspected by: Anne Borland Type of inspection: Announced (Short Notice) Inspection completed on: 6 June 2011

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 18 5 Summary of grades 19 6 Inspection and grading history 19 Service provided by: Glasgow City Council Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Anne Borland Telephone enquiries@scswis.com Kempsthorn Crescent, page 2 of 21

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 0 N/A Quality of Environment 4 Good Quality of Staffing 0 N/A Quality of Management and Leadership 4 Good What the service does well Staff at the service know the young people well and treat young people as individuals. The staff members are warm and positive in their interactions with the young people. What the service could do better The areas for improvement are to successfully resolve the bullying amongst the group of young people, improve the physical environment and increase the external monitoring of the service. What the service has done since the last inspection Risk assessments have improved and the plans for the new build are progressing. Young people are now having house meetings. Conclusion Kempsthorn continues to provide a stable environment for the young people. Staff members demonstrate commitment to improving the live situations of the young people in their care. Kempsthorn Crescent, page 3 of 21

4 Who did this inspection Anne Borland Lay assessor: N/A. Kempsthorn Crescent, page 4 of 21

5 1 About the service we inspected Kempsthorn Crescent is provided by Glasgow City Council and provides residential care for a maximum of six children and young people aged between 8 and 16 years. The accommodation is a two storey building in a residential area on the south side of Glasgow that was converted to one house from four flats. It is located within walking distance of a wide range of community resources. The aim of the service is to provide a safe, caring environment for young people who are unable to live with family members at this stage in their life. Before 1 April 2011 this service was registered with the Care Commission. On this date the new scrutiny body, Social Care and Social Work Improvement Scotland (SCSWIS), took over the work of the Care Commission, including the registration of care services. This means that from 1st April 2011 this service continued its registration under the new body, SCSWIS. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - N/A Quality of Environment - Grade 4 - Good Quality of Staffing - N/A 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. Kempsthorn Crescent, page 5 of 21

6 2 How we inspected this service The level of inspection we carried out In this service we carried out a medium intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection This short notice inspection commenced on the 2nd June 2011 by Anne Borland. The Inspector made two visits to the unit and provided verbal feedback of the findings on the 6th June During the inspection information was gathered from a number of sources including discussion with: young people, staff members and the manager. Views were also considered from four questionnaires completed by young people. A review took place of a range of documentation, including the following; Supporting evidence from the up to date self assessment 3 service users' personal plans Minutes of a service user house meeting. Complaints log book Staff supervision minutes Staff meeting minutes Violent incident reports Summary and monthly reports, Staff communication book Young peoples daily logs. The Inspector also looked at the environment. Kempsthorn Crescent, page 6 of 21

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 Kempsthorn Crescent, page 7 of 21

8 What the service has done to meet any recommendations we made at our last inspection The last inspection was carried out by the former regulating body the Care Commission. No recommendations were made following that inspection. 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 manager provided a self assessment which detailed the strengths of the service and areas for development. Taking the views of people using the care service into account The inspector spoke with three young people. All expressed that the staff at the service were fair and that they had good relationships with most staff. Young people stated they felt able to express their opinion and that their views would be listened too. Overall they felt Kempsthorn was a good place to live when having to live apart from family. All young people spoke of bullying within the home as making them unhappy at times. Young people could explain how staff intervened in the bullying to offer protection but that it still continued. Taking carers' views into account The inspector did not meet with any parents or carers as part of this inspection. Kempsthorn Crescent, page 8 of 21

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 - NOT ASSESSED Kempsthorn Crescent, page 9 of 21

10 Quality Theme 2: Quality of Environment 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 environment within the service. Service strengths Young people were encouraged to personalise their bedrooms with funds that were made available to facilitate this. Most young people have used this opportunity to create a comfortable environment. Young people were involved in discussions regarding social and recreational outings. Young people had individual time with key workers to discuss concerns, worries and wishes. The content of discussions were recorded and excellent examples of this viewed by the inspector. Plans were in place to consult with the young people regarding the new building which is proposed to replace the existing home. Areas for improvement Young people could be more involved in discussions to improve the condition of the current building. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Kempsthorn Crescent, page 10 of 21

11 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths Inspection report continued The staff group within the home were proactive in striving to provide a safe environment. Routine health and safety checks were carried and repairs reported promptly by staff. An arrangement was in place with the housing provider to carry out maintenance with smaller repairs carried out by the handy person. Environmental health inspections were carried out and there was evidence that the service was compliant with legal requirements. A door entry system was in place and a security camera covering the grounds. Staff members requested visitors sign the visitor's book and show identification, if appropriate, before being allowed entry. The home computer had appropriate restrictions in place to protect the young people from the risk of on-line abuse and to prevent access to unsuitable sites. Young people's use of mobile phones was monitored and staff took action when these were used inappropriately. Individual risk assessments were in place for young people with action plans on how to reduce or eliminate risks identified. All young people had individual crisis management plans which outlined the best approach to take with the specific young person when exhibiting crisis behaviour. Following episodes of violence staff members completed violent incident reports which gave account of the situation and the action taken. The unit manager monitored these reports. A sanctions book was used to record any with holding of privileges and it was evident sanctions used were in keeping with the organisation procedures. Young people were also rewarded for positive behaviour and achievements. The unit had good links with advocacy service, using these to good effect. The complaint procedure was known to the young people and complaints received had been responded to by staff and management. Staff at Kempsthorn Unit promoted the independence of the young people in keeping with their ability and need for safety. Young people were encouraged to attend clubs and maintain friendships outwith the home. One young person had been awarded an 'Active Citizenship Award' by Glasgow City Council. Kempsthorn Crescent, page 11 of 21

12 Areas for improvement There had been a lack of external monitoring of Violent incident reports. (Refer to recommendation 1 below) There was on ongoing issue of bullying between the young people. Whilst staff members were active in discouraging this, and close supervision of young people, it still prevailed. This was having a detrimental effect on several young people but causing extreme upset to one child in particular. (Refer to recommendation 2 below) Communal areas of the home could benefit from a deep clean and one of the bedrooms was in an unhygienic condition. (Refer to recommendation 3 below) Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 3 Recommendations 1. Recommendation with reference to Theme 2 Statement 2: Violent incident reports should be read by external management within the timescales set down in the provider's procedures. This is to meet with Standard Management and Staffing. National Care Standards for Care Homes for Children and Young People. 2. Recommendation with reference to Theme 2 Statement 2: The provider should seek to support the staff in the unit to resolve the bullying which is impacting adversely on the quality of life for some young people within the home. This is to meet with Standard Feeling Safe and Secure. National Care Standards for Care Homes for Children and Young People. 3. Recommendation with reference to Theme 2 Statement 2: Arrangements should be made for the house to undergo a deep clean and for the unacceptable standards in one of the bedrooms improved. This is to meet with Standard Your Environment. National Care Standards for Care Homes for Children and Young People. Kempsthorn Crescent, page 12 of 21

13 Statement 4 The accommodation we provide ensures that the privacy of service users is respected. Service strengths Each young person had their own bedroom and staff were observed to knock on doors waiting for permission to enter. Young people could choose to hold keys for their bedroom doors. All young people had access to lockable space within their bedrooms. The bathroom and shower rooms had working locks. All personal information regarding the young people was stored securely. There was a record of a staff member reminding staff of the need to file correspondence promptly. Areas for improvement The home currently were using agency cleaning staff. As these workers were not always know to the young people there was an interim procedure of asking young people whether or not agency staff could enter bedrooms. Whilst the principle of this was embedded in child centred practice and respecting privacy, it was not always practical when a young person was unable or unwilling to maintain their bedroom to an acceptable standard. Further consideration could take place regarding this policy. The communal space within the home was limited and could impact on privacy when visitors came to the home to meet with young people. It was hoped this would be resolved by the building of the new unit. The bathrooms did not have window coverings (Refer to recommendation below). Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. Recommendation with reference to Theme 2 Statement 4: The shower rooms and bathroom should have window dressings. This is to meet with Standard Your Environment. National Care Standards for Care Homes for Children and Young People. Kempsthorn Crescent, page 13 of 21

14 Quality Theme 3: Quality of Staffing - NOT ASSESSED Kempsthorn Crescent, page 14 of 21

15 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 home held young peoples' meetings and young people were encouraged to express their views regarding all aspects of the home. There was a good communication with parents as appropriate. Areas for improvement The manager had issued questionnaires to parents, case managers and young people and planned to use these to inform the unit's development plan. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Kempsthorn Crescent, page 15 of 21

16 Statement 2 We involve our workforce in determining the direction and future objectives of the service. Service strengths Staff members described the management as being accessible and that they were able to express their opinions and views. Team meetings were held regularly for both day and night shift staff members. Decisions made were clearly recorded. Staff described these meetings as a useful forum to discuss ideas and practices issues. Outside specialists had been invited to the home to give talks to staff on specific practice issues. Staff members had regularly supervision from line managers, a record of which was kept and signed by both parties to signify agreement. In preparation for the new building staff members had specific tasks in coordinating different areas of the house. Areas for improvement The manager identified a need to progress staff members professional development plans when the new format becomes available. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Kempsthorn Crescent, page 16 of 21

17 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 staff and manager carried out audits of the progress of young peoples' care plans and compiled weekly and monthly reports. These reports were issued to case managers and the Principle Officer of the service. The manager monitored staff practice in a number of ways: day to day observation of practice, daily recordings, complaints received, sanctions issued and violent incidents. The manager was also in daily contact with the young people and made time to seek their views. The home had good contact with the 'Who Cares?' representative who was a regular visitor to the home. Areas for improvement The homes development plan was in need of update. The manager was aware of this and progressing this was planned. The formal process of external monitoring, 'monthly sampling', had reduced in frequency and minutes were not available since the sampling visit in January (Refer to recommendation below) Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. Recommendation with reference to Theme 4 Statement 4: The frequency of external monitoring of the home should improve. This is to meet with Standard Management and Staffing National Care Standards for Care Homes for Children and Young People. Kempsthorn Crescent, page 17 of 21

18 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 N/A. 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). Kempsthorn Crescent, page 18 of 21

19 5 Summary of grades Quality of Care and Support - Not Assessed Quality of Environment Good Statement 1 Statement 2 Statement Good 4 - Good 4 - Good Quality of Staffing - Not Assessed Quality of Management and Leadership Good Statement 1 Statement 2 Statement Good 5 - Very Good 3 - Adequate 6 Inspection and grading history Date Type Gradings 15 Dec 2010 Unannounced Care and support 4 - Good Environment 4 - Good Staffing Not Assessed Management and Leadership Not Assessed 12 Aug 2010 Announced Care and support 4 - Good Environment Not Assessed Staffing Not Assessed Management and Leadership 4 - Good 30 Mar 2010 Announced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed Management and Leadership 5 - Very Good 17 Dec 2009 Unannounced Care and support 5 - Very Good Environment Not Assessed Kempsthorn Crescent, page 19 of 21

20 Staffing Management and Leadership 4 - Good Not Assessed 26 Mar 2009 Unannounced Care and support 4 - Good Environment Not Assessed Staffing Not Assessed Management and Leadership 4 - Good 15 Sep 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. Kempsthorn Crescent, page 20 of 21

21 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 SCSWIS. 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@scswis.com Web: Kempsthorn Crescent, page 21 of 21