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: Unannounced Inspection completed on: 3 October 2012

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 21 5 Summary of grades 22 6 Inspection and grading history 22 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@careinspectorate.com Kempsthorn Crescent, page 2 of 24

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 4 Good Quality of Staffing 4 Good Quality of Management and Leadership 4 Good What the service does well The young people in the service stated they were happy and felt safe and cared for by staff team. What the service could do better The medication recording systems should improve. The process to ensure adequate information is provided by social workers relating to young people should become more effective. What the service has done since the last inspection The atmosphere within the home was relaxed and happy. Staff members appeared more relaxed and stated the team morale had improved. There had been a decrease in the need to involve police in incidents within the house and in the amount of violent incidents had reduced. The physical environment was more homely and cleaner. Conclusion Most of the young people living in the unit appeared to be happier and were exhibiting less challenging behaviour. Staff members attributed good management and the staff team work to create a more secure and improved living environment for the young people. Kempsthorn Crescent, page 3 of 24

4 Who did this inspection Anne Borland Kempsthorn Crescent, page 4 of 24

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, now also known as the Care Inspectorate. 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 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. Kempsthorn Crescent, page 5 of 24

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 This unannounced inspection was carried out over two days commencing on the 26th September During the course of the inspection the Inspector spoke with three young people, five residential workers, the cook, two senior practitioners and the manager. The condition of the physical environment was examined. Relevant records were examined some of which included: The support plans for three young people, Complaints log Medication Records Violent incident recordings Young people meeting minutes Team meeting minutes Health and Safety Records Monthly manager reports Monthly care plan audits. 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. Kempsthorn Crescent, page 6 of 24

7 Fire safety issues Inspection report continued 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 24

8 What the service has done to meet any recommendations we made at our last inspection There were no recommendations made following the last 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 areas of strengths and areas for development. Taking the views of people using the care service into account The Inspector spoke with three young people, all were positive about living in the home. These young people gave examples of how they are consulted and the various activities which are offered to them. All stated feeling safe and protected by the staff. Two young people stated the home was "better now" as there was less arguments and fighting between the young people. Taking carers' views into account The Inspector did not speak with any parents or carers. Kempsthorn Crescent, page 8 of 24

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 The staff in the service engaged the young people in decision making in a number of ways. Individually young people attended formal care reviews with some young people contributing their own written report 'Having your say'. The service also operated a key worker system with staff members encouraged to spend individual time with nominated key workers. There was evidence that staff and management advocated on behalf of the young people, to the case manager, in formal settings. Young people now attended house meetings to discuss common issues and contribute to planning activities, menu planning, house rules, proposed decoration and holiday plans. This had been a significant change in the way young peoples' requests were progressed, for example, menu changes and activity planning. Young people were encouraged to personalise their own bedrooms and were allocated funds to do this. As a result the bedrooms were homely and posters and such like reflected the hobbies and interests of the young people. Young people were being consulted about the new building and plans were in place to show young people the building. The service had access to 'Who Cares?', the independent advocacy service and the organisation's Children's Rights Officer and helped young people to access these resources when needed. Young people across the residential services had been invited to take part in the recruitment of new staff. Young people living in Kempsthorn had taken part in this activity. A young person from the service was a member of the Young persons' reference group, which had been formed with young people from childrens' units throughout the Local Authority. This group met monthly. This group was contributing towards decision making regarding ongoing issues and the future development of residential services for children and young people in Glasgow. Kempsthorn Crescent, page 9 of 24

10 The service had issued questionnaires to young people and parents and had received two responses from young people and two from parents. One young person was positive about living in the service, whilst another was not. The manager had used this as an opportunity to discuss issues with the young person who was unhappy in the placement. Both parents expressed satisfaction with the care provided. However, one parent was unhappy about the amount of criminal charges his child had been involved in as a result of behaviour in the unit. The level of police involvement in the unit had decreased significantly in recent weeks. Areas for improvement The staff and management should continue to promote young people participation. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Kempsthorn Crescent, page 10 of 24

11 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths The young people had their health needs assessed by the Looked After and Accommodated Children's Nurse (LAAC Nurse). Following the assessment the LAAC nurse could make referrals for specialised services. There was evidence that young people had made use of the Sandyford sexual health services and the Child and Adolescent Mental Health services and counselling services. The LAAC nurse had also provided immunisations and advised young people on a number of matters relating to good health. Staff kept a detailed account of all health appointments which were attended by young people. The blue BAAF health books were kept up to date. Young people were supported and encouraged to attend health appointments. There was evidence of young people attending dentists and opticians for routine checkups in addition to attendance for treatment. Young people were positive about the meals provided and confirmed menus reflected their food preferences. Meals included healthy options with fresh fruit, vegetables and salad provided daily. Most of the young people ate well joining the staff for meals at the table. Physical exercise was promoted and most young people had been given the opportunity to participate in trying sport and exercise. Young people had friendships within the community and were 'playing' outdoors and benefited from fresh air and exercise and the development of social skills. Areas for improvement Inspection report continued One young person was not receiving medications as prescribed, with no explanation provided on the medication administration records. (Refer to recommendation 1 below). For one young person there was insufficient care plan information and background information despite numerous requests by the young person's key worker to the social worker to provide this. (Refer to recommendation 2 below). Kempsthorn Crescent, page 11 of 24

12 Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 2 Recommendations 1. Recommendation with reference to Theme 1, Statement 3: Medication should be administered as prescribed or if refused this should be recorded on the medication administration sheets. This is to meet with Standard 12.6 Keeping Well -Medication. National Care Standards for Care Homes for Children and Young People. 2. Recommendation with reference to Theme 1, Statement 3: The management of the service should ensure systems are in place to ensure adequate care plan documentation and information is received from social workers when a young person is admitted to the unit. This is to meet with Standard 4.1 Support Plans. National Care Standards for Care Homes for Children and Young People. Kempsthorn Crescent, page 12 of 24

13 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 Please refer to Theme 1, Statement 1. Areas for improvement Please refer to Theme 1, Statement 1. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Kempsthorn Crescent, page 13 of 24

14 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths Inspection report continued At the time of the inspection the house was clean, tidy and some improvement had been made in the presentation, in terms of homely touches. The previous management office had been de-cluttered and was now a second sitting room for the young people. Young people were helped to maintain a clean and safe environment and were supported to keep their bedrooms tidy and clean. Bedrooms had improved in terms of attractiveness. The cook followed safe food handling and hygiene practices. Cooked food and fridge temperatures were monitored. Electrical equipment testing was carried out routinely and gas equipment was serviced annually. Recent certificates indicated that all was in order. The service had regular legionella checks to ensure the water was safe for use. Water temperatures were also kept to prevent burns or scalds. The service has a visitors' sign in book and visitors were asked to show identification when appropriate. There was an oncall system in place for staff to contact management in an emergency, outwith office hours. Staff at the service could also contact the West of Scotland Social Work Standby Service if necessary. An out of hours team, comprising of residential workers, were based in the city for the purpose of responding to emergency additional staffing needs. The service also held contact details for emergency services such as, NHS 24, Police and Fire Service. The property was maintained by City Building Repairs team who could also be contacted to attend to urgent repairs to the fabric of the building. There was evidence of the staff making contact to these services as needed. There was a prompt response for non urgent repairs by the City Building team and the house was in a good state of repair. Staff member completed Violent Incident forms (VI1) to record any incident which involved the young person showing aggression, violence, verbal abuse, or threat of aggression towards a staff member or other young person. This included an account of how the situation arose, what happened and the action which was taken to manage the situation. These were signed by the manager. There had been a decrease in incidents in recent weeks. Kempsthorn Crescent, page 14 of 24

15 Procedures were in place to alert RIDDOR of notifiable incidents. Staff members recorded any sanction imposed on young people as a consequence of inappropriate behaviours. The service was using a rewards system to promote positive behaviour. Staff members undertake Therapeutic Crisis Intervention training to develop skills in intervention techniques to use in managing behaviour. This training had been regularly updated. Risk assessments were in place for young people identifying a number of potential risks to themselves and others. Management plans were in place to manage, reduce or eliminate risk. The service had 'Substance Misuse' procedures, which made clear the action to be taken in the event of a young person returning to the service under the influence of drugs and/or alcohol. There were records of the monitoring of young people during the period of time in which they were under the influence of substances. Individual Crisis management plans were in place and identified the circumstances in which a young person may become distressed and exhibit challenging behaviours. Staff members were trained in Child Protection and were aware of the procedures to follow in the event of a young person being at risk of danger and when to report allegations of abuse. Staff members followed the provider 'Missing from Placement' procedures when young people failed to return to the place. This involved notifying parents and the police. The home operated a traffic light system in partnership with the police in the event of a young person being missing from the placement. This code system allowed for a level of priority to be given in seeking out the young person dependent on the assessed level of vulnerability. Areas for improvement The risk management plans for young people lacked specific detail of the current good practice being used by staff to minimise risk behaviour. The manager advised these were currently been audited. There was a delay by the provider to act on decisions being made following a risk assessment. However, this was being addressed at the time of inspection. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Kempsthorn Crescent, page 15 of 24

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 Please refer to Theme 1, Statement 1. Areas for improvement Please refer to Theme 1, Statement 1. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Kempsthorn Crescent, page 16 of 24

17 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths Staff were very positive about the management and stated they felt supported and valued. Regular team meetings were held. There was evidence of good systems of communication between staff teams. This included the use of a staff planner with tasks allocated daily, informative shift handover and good use of the staff communication book. The majority of staff members were qualified to SVQ level 3 and HNC or above. Mandatory refresher training was made available and staff could access the Glasgow Online training resource (GOLD) for further training. Staff members stated that over the last year training opportunities had improved. As a result some has attended additional non mandatory training events. Staff members were registered with the Scottish Social Service Council (SSSC). Areas for improvement The frequency of supervision was not in keeping with the provider's policy. This was attributed to priority being given to working to create a more settled home for the young people after a particularly difficult time. The new manager was addressing this issue and dates for staff supervision had been agreed. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Kempsthorn Crescent, page 17 of 24

18 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 Please refer to Theme 1, Statement 1. Areas for improvement Please refer to Theme 1, Statement 1. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Kempsthorn Crescent, page 18 of 24

19 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 service has a quality assurance document which guides staff on best practice in regards to seeking the views of service users and stakeholders on how the service can improve. The external manager was a regular visitor to the home and met with the manager regularly to discuss issues and progress made in the service.the external manager also attended senior management meetings. The senior night workers carried out record sampling to monitor practice. The manager provided the external manager with a monthly report, which reported on all aspects of the service performance. This included an examination of complaints, violent incidents, staff attendance, Heath and Safety, staff training and the progress of the young people. The manager met regularly with the head of residential services and service manager to discuss operational issues and progress of the young people. Meetings also took place with Personnel to discuss any staffing issues and the Finance section to discuss budget management. Weekly reports were sent to case managers regarding the progress of young people. Monthly care plan audits were sent to external management to ensure appropriate progress was being made. Notifications are made as appropriate by the service to the SSSC and the Care Inspectorate. The service had a complaints system which was known to the young people. The organisation used electronic survey monkeys to gather staff views on a range of subject, with the latest being regarding training for residential child care workers. The results are to be used to inform the future training programme. Areas for improvement There were a number of complaints made by the young people outstanding, with no record of investigation or resolution. This was prior to the current management being in place. The manager and external manager advised that information was being collated to allow for the complaints to be investigated. ( Refer to recommendation below). The manager was planning to update the service's development plan to take account of the views of staff, young people and other stakeholders. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 1 Inspection report continued Kempsthorn Crescent, page 19 of 24

20 Recommendations Inspection report continued 1. Recommendation with reference to Theme 4, Statement 4: The provider should provide the Care Inspectorate of their action plans detailing how the complaints made by young people, including an ex-resident will be investigated. This is to meet with Standard 18.6 Concerns, Comments and Complaints. National Care Standards for Care Homes for Children and Young People. Kempsthorn Crescent, page 20 of 24

21 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 21 of 24

22 5 Summary of grades Quality of Care and Support Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Environment Good Statement 1 Statement Very Good 4 - Good Quality of Staffing Good Statement 1 Statement Very Good 4 - Good Quality of Management and Leadership Good Statement 1 Statement Very Good 3 - Adequate 6 Inspection and grading history Date Type Gradings 10 Jan 2012 Unannounced Care and support Not Assessed Environment 4 - Good Staffing Not Assessed Management and Leadership 4 - Good 6 Jun 2011 Announced (Short Notice) Care and support Environment Staffing Management and Leadership Not Assessed 4 - Good Not Assessed 4 - Good 15 Dec 2010 Unannounced Care and support 4 - Good Environment 4 - Good Staffing Not Assessed Management and Leadership Not Assessed Kempsthorn Crescent, page 22 of 24

23 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 Staffing 4 - Good Management and Leadership 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 23 of 24

24 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: Kempsthorn Crescent, page 24 of 24