Barnardo's - Melbourne House Holiday Activity Programme Day Care of Children Melbourne House 94 Mid Street Bathgate EH48 1QF

Transcription

1 Barnardo's - Melbourne House Holiday Activity Programme Day Care of Children Melbourne House 94 Mid Street Bathgate EH48 1QF Inspected by: Joanna Westwater Type of inspection: Unannounced Inspection completed on: 23 October 2012

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 10 4 Other information 21 5 Summary of grades 22 6 Inspection and grading history 22 Service provided by: Barnardo's 'known as' Barnardo's Scotland Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Joanna Westwater Telephone enquiries@careinspectorate.com Barnardo's - Melbourne House Holiday Activity Programme, 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 4 Good Quality of Environment 4 Good Quality of Staffing 5 Very Good Quality of Management and Leadership 4 Good What the service does well The service provided a caring and stimulating environment for children to play, learn and develop. The staff team had developed communication methods to use with the children and were committed to providing a quality service. Staff provided opportunities for families to contribute their views and took account of these views. The staff promoted a child centred approach and planned activities and outings that took account of children's interests and abilities. What the service could do better The service should consider how to further develop their child centred approach and involve children and young people more fully in planning activities. The service should also consider how to involve all interested people in their quality assurance processes. Infection control measures should be reviewed with staff to ensure procedures are carried out as detailed in the service's policy documents. What the service has done since the last inspection Since the last inspection the service had developed ways to get the views of the children and young people. Staff had also developed the children and young people's individual support plans. Barnardo's - Melbourne House Holiday Activity Programme, page 3 of 24

4 Conclusion Inspection report continued Barnardo's - Melbourne House Holiday Activity Programme provided a number of services to children and young people with additional support needs during holidays and at weekends. The service was valued by the families and staff were committed to providing a caring and stimulating service that met individual needs. Who did this inspection Joanna Westwater Barnardo's - Melbourne House Holiday Activity Programme, page 4 of 24

5 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 Requirements and recommendations If we are concerned about some aspect of a service, or think it could do more to improve its service, we may make a recommendation or requirement. - A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service but where failure to do so will not directly result in enforcement. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reforms (Scotland) Act 2010 and Regulations or Orders made under the Act, or a condition of registration. Where there are breaches of the Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Inspectorate." The Holiday Activity Programme (HAP) was provided by Barnardo's West Lothian Family Support Team and provided a day care service for children and young people with a variety of additional support needs on a 1:1 staff child ratio. The service operates outwith school hours on a Monday - Friday 9.00am pm and 10.00am pm on a Saturday. The HAP is registered to provide a care service to a maximum of 32 children aged 2 years - 16 years. There was a combination of permanent staff, paid sessional staff and volunteers who work throughout the HAP. The service was provide from Melbourne House, in Bathgate, Beatlie School Campus in Livingston, Deans Community High School in Livingston and from Strathbrock Family Unit in Broxburn. The service had access to play rooms, equipment and resources that were suitable to meet the needs of the children and young people who used the service. The aims of West Lothian Family Support Team included: 1. Provide Disability Support Services to children and young people, from birth to school leaving age, with significant learning disabilities (including complex health needs). 2. Provide Family Support Services to parents and carers of children and young people who access the Disability Service. Barnardo's - Melbourne House Holiday Activity Programme, page 5 of 24

6 3. Provide Short Breaks Services to parents and carers of children and young people who access the disability service through home sitting and activity sessions. At the time of the inspection there were seven children and young people attending the service. 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 Environment - Grade 4 - Good Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 4 - Good This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. Barnardo's - Melbourne House Holiday Activity Programme, page 6 of 24

7 2 How we inspected this service The level of inspection we carried out In this service we carried out a low intensity inspection. We carry out these inspections when we are satisfied that services are working hard to provide consistently high standards of care. What we did during the inspection The inspection was carried out by Inspector Joanna Westwater on 16 October 2012 between 11am and 2pm. Discussion and feedback with the manager of the service took place on 23 October between 1pm and 3pm. Ten Care Standards Questionnaires were issued to parents who used the service and three were returned to us before the inspection. In this inspection evidence was gathered from various sources, including relevant sections of the policies, procedures, records and other documents, including: * Evidence from the service's self assessment * Incident and accident reports * Activity plans and evaluations * Parent/carer feedback * Children's profiles * Aims and objectives of service * Photographs * Record of children's attendance * Observing staff's interaction with the children * Observing staff practice * Examination of resources * Discussion with the manager and staff 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 Barnardo's - Melbourne House Holiday Activity Programme, page 7 of 24

8 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 Barnardo's - Melbourne House Holiday Activity Programme, page 8 of 24

9 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 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 improvement and any changes they had planned. The service provider told us 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 There were seven children and young people using the service at the time of the inspection. Two of the children were on a swimming trip. The remaining children were unable to verbalise their views about the service and were observed to appear confident and secure with the staff and volunteers caring for them. Taking carers' views into account Three parents/carers returned Care Standards Questionnaires to us prior to the inspection. A telephone call to one parent/carer was not returned. The views and comments made in the questionnaires are included under the quality statements in the report. Barnardo's - Melbourne House Holiday Activity Programme, page 9 of 24

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 found this service was performing to a good standard in the areas covered by this statement. We concluded this after we spoke with staff and the manager, considered parent/carer feedback from the Care Standards Questionnaires, looked at children's and young people's records and observed the children and young people who were present during the inspection. The service used a number of ways to encourage parents/carers and children and young people to give their views about the service and to influence service development, including the following: *discussion with parents/carers at home visits *parent/carer questionnaires and evaluations *staff planning with the children/young people *informal daily chats *newsletters *daily feedback sheets *complaints procedure *staff knowledge of the children and their observations of children - used to plan activities Staff were observed responding to and interpreting children's/young people's behaviour. This meant that children's/young people's immediate needs and preferences were listened to and provided for. Barnardo's - Melbourne House Holiday Activity Programme, page 10 of 24

11 Staff and volunteers knew the children well and this helped them plan activities that the children enjoyed. A picture card card system was used with children/young people to get their views and to show the children/young people what was happening next. At the end of each daily session, staff completed a recording sheet for parents/carers detailing what their child had done, what they enjoyed and any relevant observations. Some children took part in this activity with staff. The service had started a newsletter for parents/carers and had issued two newsletters this year. This had been in response to a recommendation made at the last inspection that information was provided to parents/carers about the service on a regular basis. In response to parents'/carers' requests to increase the number of places available for children and young people, the service had provided this increase when they had the required number of staff and volunteers. The service had also responded positively to a request from a parent that information about the activity programme be provided earlier in the year. Two parents/carers who gave us feedback, indicated they strongly agreed that they were happy overall with the quality of care their child received in the service. One parent agreed with this statement. Two parents/carers also agreed that they had received clear information about the service before their children started to use it. One parent/carer disagreed with this statement. In response to the statement, 'The service has involved me and my child in developing the service, for example asking for ideas and feedback,' one parent/carer strongly agreed with this statement, one parent/carer agreed with this statement and one parent/carer disagreed. This feedback was discussed with the manager of the service who agreed to give the responses consideration. Areas for improvement The service should continue to develop ways to gain views and opinions about the service from parents/carers children and young people. They should use this feedback to make improvements in the service and should tell parents/carers, children and young people about these improvements. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Barnardo's - Melbourne House Holiday Activity Programme, page 11 of 24

12 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Inspection report continued We found this service was performing to a good standard in the areas covered by this statement. We concluded this after we spoke with staff, looked at children's records and relevant policies and procedures. We also observed the environment, children's activities and children's snack time. An effective system was used to provide staff and volunteers with up to date daily information about the children/young people. This helped them design daily care programs that were meeting the children's/young people's needs. Staff were matched with children/young people to ensure continuity of care whenever possible. A range of measures were in place to help staff ensure the children's/young people's health and wellbeing needs were met that included the following: * appropriate health and safety procedures that were understood by staff * staff had attended relevant training in first aid, child protection and food hygiene. Staff told us that training meant they were more confident about measures to take to keep the children and young people safe * a secure door entry system controlled access to the centre * staff were aware of the procedures to follow to alert the provider when there were maintenance and repair issues * consultation with other agencies helped staff to provide support for individual children/young people. We looked at records which showed children's and young people's needs and requirements. This information was reviewed with parents/carers and used by staff to plan activities. Plans also showed that children's and young people's ideas had influenced activities. Some staff knew the children and young people very well. This meant that activities and opportunities were provided to meet individual needs. We saw that staff were skilled in supporting children and young people to make choices when possible. This provided opportunities for the children and young people to build self confidence. Children and young people had access to a range of activities that included swimming and outings to the science centre and visits to parks. Parents/carers provided packed lunches. Staff told us that these packed lunches were usually healthy options. Staff sat with the children and young people at meal times and encouraged a social and fun atmosphere. Barnardo's - Melbourne House Holiday Activity Programme, page 12 of 24

13 Parents/carers who made comment told us that they were happy with the way staff cared for their children and that they were confident that the children's/young people's health and well being needs were met by the service. Further comments included the following: 'I feel that they know my child well and although he doesn't talk they have learned what he likes and arrange activities he will enjoy and (that) meet his needs. They are also keen to use alternative communication and visual timetable with my son as this is what he needs.' 'My daughter enjoys the varied activities and trips each year. My daughter's needs and development changes each year. I think it would be beneficial to staff and parents to have each child's profile updated each year. Parents could then document current needs...' These comments were discussed with the manager of the service who agreed to give consideration to the views expressed. Areas for improvement Although staff wore gloves when carrying out personal care routines for the children/ young people, they did not wear aprons to control the spread of infection. This was noted at the last inspection and a recommendation was made that appropriate measures should be taken to control the spread of infection.this issue was discussed with the manager who told us that their infection control procedures stated that aprons should be worn in this circumstance. A requirement has been made about this. See requirement 1. Not all children's and young people's profile folders contained a photograph. In discussion with the manager, she agreed to address this issue and ensure that all children and young people would have the opportunity to recognise their folders. This action would also support new volunteers and staff to get to know the children and young people. One of the sessional staff had suggested that staff and volunteer photographs were used to identify to parents/carers who would be caring for their child at each session. The staff had proposed that a notice board at the door of the play room be used to display this information. The manager agreed to consider this proposal. Grade awarded for this statement: 4 - Good Number of requirements: 1 Number of recommendations: 0 Inspection report continued Barnardo's - Melbourne House Holiday Activity Programme, page 13 of 24

14 Requirements Inspection report continued 1. The provider must ensure all staff are aware of and follow the appropriate procedures to prevent the spread of infection. Infection control training should be provided for all staff. This is in order to comply with Scottish Statutory Instrument 2011/210 Regulation 4(1)(a) - A provider must make proper provisions for the health, welfare and safety of service users. In making this requirement we took account of the national care standards for Early Education and Childcare up to the age of 16: Standard 2 A safe environment, Standard 3 Health and wellbeing. Timescale: This requirement must be addressed on receipt of this report. Written confirmation how this requirement will be met must be sent to the Care Inspectorate by December 4th Barnardo's - Melbourne House Holiday Activity Programme, page 14 of 24

15 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 See Quality Statement 1.1 for supporting evidence. In addition the service stated in the self assessment document that they planned to review the evaluation forms issued to parents/carers and issue these later in the year. One parent/carer requested her child be taken swimming and this had taken place. Young people had been involved in planning a parents/carers evening. Areas for improvement As Quality statement 1.1 Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Barnardo's - Melbourne House Holiday Activity Programme, page 15 of 24

16 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths We found this service was performing to a very good standard in the areas covered by this statement. We concluded this after we spoke with staff, had feedback from parents, examined policies and procedures and observed the premises. At the time of the inspection we saw that the premises was in a good state of repair and was clean. The playrooms were bright and airy with appropriate heating and lighting. These measures provided a welcoming environment for the children and young people. We saw that there was a secure door entry system in operation as were appropriate cleaning procedures, safety checklists and risk assessments for the premises, activities and outings. Staff were aware of the procedures to follow to alert the provider when there were maintenance or repair issues. Staff confirmed repairs were addressed within good timescales. Staff had attended training to enable them to maintain a safe environment for the children. Appropriate toileting facilities were available for the children and young people. Equipment and resources were suitable for the children and young people using the service and were stored in ways that enabled children, who had the capacity, to have free access to some activities of their choice. Parents/carers, who made comment, indicated they agreed or strongly agreed that the service was a safe, secure pleasant and stimulating environment for the children and young people. Areas for improvement The manager agreed to ensure that risk assessments undertaken for activities were shared with volunteers before each session. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Barnardo's - Melbourne House Holiday Activity Programme, page 16 of 24

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 See Quality Statement 1.1 for supporting evidence. In addition, parents had been involved in interviews for new staff and had completed evaluations forms about existing staff. Information gained from these processes was discussed with staff. Areas for improvement As Quality Statement 1.1. In addition, the service stated they planned to involve parents in the induction process for volunteers. Grade awarded for this statement: 5 - Very Good Number of recommendations: 0 Number of requirements: 0 Barnardo's - Melbourne House Holiday Activity Programme, page 17 of 24

18 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths We found this service was performing to a very good standard in the areas covered by this statement. We concluded this after we spoke with staff, had feedback from parents and examined policies and procedures. The staff and volunteer group were enthusiastic and committed to their involvement in the improvement of the service and to the quality experiences offered to children and young people. They offered continuity of care for the children. Staff we spoke with confirmed they were given opportunity to attend appropriate training courses, for example in first aid, child protection, infection control and use of the ipad. Staff were appropriately qualified to undertake their job roles and attended training required for registration with Scottish Social Services Council (SSSC). An effective staff development programme also identified training needs and opportunities that reflected the needs of the children and young people using the service, the needs of the service and staff personal development. A training plan was in place to record this. The staff kept up to date with best practice guidance and current legislation and used this to support their practice. Links with other professional organisations such as the Scottish Autistic Society also provided staff with up to date information. This meant that children and young people received a service where their needs could be identified and provided for, by a professional and skilled team. Parents/carers who gave feedback indicated they agreed or strongly agreed that staff had the skills and experience to care for the children. Areas for improvement The service should continue to provide appropriate opportunities for staff and volunteers to keep up to date with current best practice and legislation. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Barnardo's - Melbourne House Holiday Activity Programme, page 18 of 24

19 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 4 - Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths See Quality Statement 1.1 for supporting evidence. The complaints procedure and parents'/carers' feedback had led to improvements being made in the quality of management and leadership. Areas for improvement As Quality Statement 1.1 In addition, the service identified that they planned to ensure that new evaluation forms were given to all parents/carers who received a service. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Barnardo's - Melbourne House Holiday Activity Programme, page 19 of 24

20 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 this service was performing to a very good standard in the areas covered by this statement. We concluded this after we spoke with staff and the manager. The following information was available for people who used the service and to other agencies involved with the service: * The annual report * The development plan * The statement of aims and objectives which reflected the ethos of the service * Complaints procedure The manager and team leader in the service measured quality of provision using a variety of methods including - Monitoring of staff practice through observation, supervision, appraisals and training audits. Audits were recorded and reviewed regularly to meet identified targets. Management also sampled files every six months and attended quarterly stakeholder meetings. The manager attended meetings with partners that included social work and education and this supported her to keep abreast of current best practice and legislation. Parents'/carers' evaluation forms were also completed for every piece of work undertaken by staff. Feedback from these surveys, audits and evaluations had been considered when the service completed the self assessment document. The service had submitted all required notifications to the Care Inspectorate and other professional bodies. Areas for improvement In the self assessment document the service identified that they planned to review the frameworks they used to measure outcomes for the service. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Barnardo's - Melbourne House Holiday Activity Programme, 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 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). Barnardo's - Melbourne House Holiday Activity Programme, page 21 of 24

22 5 Summary of grades Quality of Care and Support Good Statement 1 Statement Good 4 - Good Quality of Environment Good Statement 1 Statement Good 5 - Very Good Quality of Staffing Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Management and Leadership Good Statement 1 Statement Good 5 - Very Good 6 Inspection and grading history Date Type Gradings 30 Jul 2010 Unannounced Care and support 5 - Very Good Environment 5 - Very Good Staffing Not Assessed Management and Leadership Not Assessed 21 Aug 2009 Unannounced Care and support 5 - Very Good Environment 4 - Good Staffing 5 - Very Good Management and Leadership 5 - Very Good 15 Jul 2008 Unannounced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good Barnardo's - Melbourne House Holiday Activity Programme, page 22 of 24

23 All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Barnardo's - Melbourne House Holiday Activity Programme, 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: Barnardo's - Melbourne House Holiday Activity Programme, page 24 of 24