Capability Scotland - Sycamore Service Day Care of Children Westerlea 11 Ellersly Road Edinburgh EH12 6HY Telephone:

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1 Capability Scotland - Sycamore Service Day Care of Children Westerlea 11 Ellersly Road Edinburgh EH12 6HY Telephone: Type of inspection: Unannounced Inspection completed on: 25 March 2015

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 11 4 Other information 29 5 Summary of grades 30 6 Inspection and grading history 30 Service provided by: Capability Scotland Service provider number: SP Care service number: CS If you wish to contact the Care Inspectorate about this inspection report, please call us on or us at Capability Scotland - Sycamore Service, page 2 of 31

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 4 Good Quality of Management and Leadership 4 Good What the service does well Staff know the needs of the young people attending the service very well and actively engaged them in developing life skills to enhance their daily lives. The service effectively worked with other agencies to implement and review personal care plans to meet the health, wellbeing and safety needs of young people attending the service. What the service could do better Corporate Improvement plans were in place. However, quality assurance systems and participation strategies to show how service specific priorities are identified, implemented and monitored were not formalised and therefore did not provide a clear focus to improve outcomes for people who use the service and staff. What the service has done since the last inspection The responsive staff team promoted very good opportunities to engage young people in making informed decisions about their daily lives. This approach was well documented in personal plans and through staff working with other agencies. The service continued to receive commissioned referrals from Edinburgh City Council, Visiting Teaching and Support Services (VTSS). Capability Scotland - Sycamore Service, page 3 of 31

4 Conclusion Inspection report continued Overall the service provides a high level of care and support to meet the needs of young people. Quality assurance systems could be improved to include a service specific improvement plan agenda to monitor achievements made and identify future areas of improvement. Capability Scotland - Sycamore Service, page 4 of 31

5 1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Information about all care services is available on our website at If we are concerned about some aspect of a service, or think, it needs to do more to improve, 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 were failure to do so will not directly result in enforcement. Recommendations are based on the National Care Standards, relevant codes of practice and recognised good practice. * A requirement is a statement, which sets out what is required of a care service to comply with the Public Services Reform (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 Care Inspectorate. This is the second inspection of this service since registration dated 1 February Capability Scotland - Sycamore Service is based at Westerlea, Capability Scotland Headquarters, Edinburgh. The service is delivered in partnership with the City of Edinburgh Council, Visiting Teaching and Support Services (VTSS). The service provides an additional, complementary support service to pupils of mainstream high school who have an autism spectrum disorder and who, are not currently able to access the full school curriculum or full school day due to difficulties associated with an autism spectrum disorder. Young people attend the service for one or two, five hour days per week and are offered a range of tailored activities planned in partnership with VTSS. Two young people were in attendance on the day of the inspection. This service aims to: "Work in partnership with VTSS staff, the young people and their family to provide a range of opportunities and experiences for the young person to experience success, develop confidence and, in time, return to full-time mainstream school placement. To achieve this the Capability Staff will: Receive referrals from City of Edinburgh Council. Be involved in and engage in joint planning process with the young person and VTSS staff. Capability Scotland - Sycamore Service, page 5 of 31

6 Evaluate and report progress and report to all at the Child's Planning Meeting. When targets are achieved, support the young person's transition back to a full time mainstream school placement." A full statement of aims and objectives were available and were evident during the course of the inspection. 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 4 - Good Quality of Management and Leadership - Grade 4 - Good Inspection report continued 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. Capability Scotland - Sycamore Service, page 6 of 31

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 We wrote this report following a short notice inspection which took place on Wednesday 25 March 2015 between 8.00 am and 4.30 pm. Feedback was given to the acting manager on the same date. As part of the inspection process, we took account of the completed annual return that we asked the provider to complete and submit to us. The acting manager submitted the services self assessment prior to the inspection. We sent three care standards questionnaires to the service to distribute to parents. No questionnaires were returned prior to the completion of this report. During the inspection process, we gathered evidence from various sources including the following: We spoke with the acting manager, two staff and two young people. We looked at: Aims and objectives of the service. Young people's profiles and care plans. Administration and storage of medication. Health and safety records, including risk assessment, hygiene and infection controls, security. Accident and incident reports. Complaints policy. Environmental checks. Staff files, training records and appraisals. Quality assurance monitoring and evaluation systems. We also observed staff interactions with young people and accompanied them on an outing in the local community. Capability Scotland - Sycamore Service, page 7 of 31

8 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 report continued 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 Capability Scotland - Sycamore Service, page 8 of 31

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 provider. We were satisfied with the way the provider completed this and with the relevant information included for each heading that we grade services under. The provider identified what it thought the service did well, some areas for development and any changes it had planned. The 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 We spoke with two young people who were present on the day of the inspection. Through discussion, they informed that they enjoyed coming to the service and liked having lunch and playing chess with staff. Comments included: "I am going to get my travel pass. I have to take my photograph and will get my travel pass to let me travel on the bus. I like having my lunch my favourite is chicken. I am going to buy my lunch at the shops. I do not have a lot of money with me today." "I like to play chess and pool. I do not like baking, I do not like maths or physics. I like coming here I do not like school especially P.E. I like playing basketball outside. Capability Scotland - Sycamore Service, page 9 of 31

10 Taking carers' views into account Inspection report continued We sent three care standards questionnaires to the service to distribute to parents. No questionnaires were returned prior to the completion of this report. No parents/ carers were available during the course of the inspection. Capability Scotland - Sycamore Service, page 10 of 31

11 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 After sampling documents provided and through discussions with staff, acting manager and young people we found that this service was performing to a good grade. We observed a major strength was the choices and opportunities young people had to influence decisions made about their daily experiences whilst attending the service. This process was supported by the key worker systems (named member of staff who had responsibility to support the individual needs of young people). We saw staff actively engage with young people on a one to one basis during daily planning meetings. We found this approach enabled young people to plan their daily routine, evaluate their progress and identify activities they wished to do in the local community and within the service. Young peoples views therefore informed the way the service was organised and we could see staff provided time, resources and opportunities to extend children interests, suggestions and ideas. We found this approach had a positive impact on the quality of young people's daily lives, experiences and learning. The acting manager informed that due to the nature of the service, the main focus for parental involvement related to planning and assessing the health and wellbeing needs of their child. We found staff effectively used a variety of recording systems to maintain open lines of communication, including: Capability Scotland - Sycamore Service, page 11 of 31

12 Telephone and correspondence. Daily communication diary used to inform all full time and part staff of relevant information, including, appointments, attendance, dates of planning meetings, reviews, staff training and organisational issues. Transport arrangements. Records of informal and formal discussions held in personal plans. Open door policy. Minutes of meetings, including staff, management, VTSS, schools and other agencies. Daily young persons planning meetings. Planned reviews of young persons plan, attended by staff, parents/carers, young person and other agencies. Key worker system. Through sampling relevant documentation we concluded that effective communication systems were in place to enable staff to share and respond to information requests from by parent/carers, young people and other agencies. Complaints procedures were available to enable people who use the service to raise any concerns with the service provider. We found the Young Persons Planning Meeting provided opportunities for all parties to raise any issues or concerns they may have. Staff informed that they had not received any formal or informal complaints from people who use the service, since the last inspection and through discussion we were confident any issues raised would be addressed appropriately by the staff team. Areas for improvement Inspection report continued The provider identified the following areas for improvement in the services self assessment: "Revise Sycamore's Customer Involvement LOP to ensure we are optimising opportunities for Service User's to be directly involved in improving the service they receive. Provide parents and service users with an anonymous service evaluation form. The anonymity may give parents and service users the confidence to provide a more in depth and truthful evaluation of the service." We viewed a generic 'Customer Survey January 2015' which the provider had recently issued, (pictorial format) to seek the views of people who use Capability Scotland services. We discussed the use of other techniques that would allow young people, parents and carers to fully engage them in identifying and evaluating service specific improvements and achievements. See Recommendation 1, Quality Theme 1, Quality Statement 1. Capability Scotland - Sycamore Service, page 12 of 31

13 This recommendation is relevant to all four quality themes. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. The provider should consider a variety of techniques to engage people who use this service in identifying and evaluating service specific improvements and achievements. National Care Standards early education and childcare up to the age of 16: Standard 13 - Improving the service. Capability Scotland - Sycamore Service, page 13 of 31

14 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths As part of this inspection, we have focused on how the service had promoted young people health and wellbeing through infection prevention measures. We found this service to have a very good performance in relation to this statement after we sampled the following: - Young peoples personal plans and planning diaries. - Additional support needs systems and records. - Medication systems and records. - Child protection policy and procedures. - Aspects of infection control and prevention. The promotion of health and wellbeing is an important part of the work carried out in this service. Staff provided a variety of experiences to help young people learn about keeping safe, healthy and active. We observed, children benefited from learning and developing skills they needed to support them in their daily lives. Staff had participated in Getting It Right for Every Child (GIRFEC) training sessions and discussions. This had helped staff to focus on what makes a positive difference to young people and how they can work with families and other agencies to take forward a holistic approach, and make adjustments to the planned care when needed. We found this approach promoted strategies to equip young people with a greater understanding of relationships, emotions, independent thinking, selfesteem and behaviour strategies. Flexible arrangements were in place to support young people throughout their placement. This included, part time sessions with identified key workers and planned programmes to support transitions to and from secondary school. Young people had opportunities to settle into the service and we could see this approach continued to build confident relationships with staff and their peers, in a nurturing environment. This approach benefited the children, as it took account of their different needs and sensitivity to individual circumstances. For example, we observed a key worker encourage a young person to make compromises when deciding when he would do certain activities and highlighting the impact of his actions on others. The young person told us: Capability Scotland - Sycamore Service, page 14 of 31

15 "I would like to go outside now, but I do not want to play basketball with anyone else, so I am going to play badminton with (key worker named)." Following further discussions with his key worker the outcome was very positive as we later observed both young people present engaging happily in a game of basketball. This example showed how children were gaining an understanding of making compromises, which was replicated successfully throughout the day. Each young person had a personal plan which staff effectively updated daily to inform the planned care and learning needs of individual young people. These were supported by daily planning meetings which provided very good opportunities for young people to inform and evaluate what they would like to do, when they would like to do it and to discuss any areas that they may be concerned about. Through our discussions with staff and from sampling young people personal plans, we were able to determine that staff knew the young people in their care very well and that they took account of their individual needs, routines and preferences in their day-to-day experiences. This contributed positively to the young people's experiences when in the service and wider community. Due to the nature of this service, management and staff had developed effective partnerships with parents and various external agencies to identify and provide all young people and their families with individual help and assistance when required. For example, putting in place detailed transition programmes and additional support whilst attending school. They meet regularly as a multi-agency support group to monitor and review young children's progress. Additionally, staff could tell us of individual supports to enable young people to achieve skills associated with the modules they are undertaking. As a result, young people were well supported and their learning, safety and welfare needs addressed. Capability Scotland Child and Adult Protection provided a staff training framework to keep their skills and knowledge up to date. Management and staff demonstrated a clear understanding of their roles and responsibilities with regards to protecting children from harm, in line with the service child protection policy. This helped keep children safe. The children were observed demonstrating an understanding of personal hygiene as they washed their hands before snack and after using the toilet. This helped to minimise the possible spread of infection. We saw that children enjoyed a very sociable snack time. They were learning about what foods were healthy or not, choices they could make, to be responsible through clearing away the dishes they had used, caring for others and their environment. They told us; "We always sit together at snack and I buy my own lunch at the shops. I like one shop because it is cheaper than the others." Capability Scotland - Sycamore Service, page 15 of 31

16 We observed staff's practice which evidenced that they followed policies and procedures and promoted good infection control practice. For example; in preparing children's snack. To support this, they maintained records in line with the Food Standards Agency to promote positive outcomes for young people. Areas for improvement The provider identified the following areas for improvement in the services self assessment: "Team leader to continue to ensure staff training is up to date so that we can meet the needs of anyone attending the service. This will allow us to concentrate on delivering the service to the highest possible standard and react appropriately when emergency referrals arrive at the service." We discussed the services administration and storage of medication policy and procedures. Staff explained that if a child needed medication this would be planned at the time of admission. However, we discussed the procedures for storing and administering short term medication brought into the service to meet a particular ailment. Staff informed that as this situation had never arose they would seek guidance. We advised of current best practice guidance for registered service, available on the Care Inspectorate HUB. See Recommendation 1, Quality Theme 1, Quality Statement 3. Staff had developed an understanding of GIRFEC and could tell us how their practice influenced outcomes for young people. We discussed further development of young peoples personal plans to show how the associated GIRFEC wellbeing indicators informed outcomes for young people. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The provider should review the administration and storage of medication policy to ensure effective procedures are known to staff, and are in line with current best practice guidance available on the Care Inspectorate HUB - Management of medication in daycare of children and childminding services - publication code HCR Capability Scotland - Sycamore Service, page 16 of 31

17 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 We found this service to have a good performance in relation to this statement after we sampled children's and parents' participation methods. Management and staff used the same methods, to allow children and parents to participate in assessing and improving the quality of the environment, as those described in Theme 1, Statement 1. Staff encouraged children to raise funds to support activities and resources they would like to use within the service and local community. Children confidently told us how they had baked cakes and sold them to fund a trip to a local pool hall. This fund raising activity was planned in line with ASDAN project work which promoted opportunities for young people to develop social skills through cooperating with others during the baking activity, recognising the value of money, and making compromises to agree a venue for their outing. In consequence, we found staff effectively utilised activities to engage children in participating in learning experiences underpinned by the hidden curriculum, ASDEN project. Areas for improvement The provider identified the following areas for improvement in the services self assessment: "Continue to promote a customer led service that allows to maximise the likelihood of positive outcomes." We discussed the use of other techniques that would allow young people, parents and carers to fully engage them in identifying and evaluating service specific improvements and achievements. See Recommendation 1, Quality Theme 1, Quality Statement 1. Capability Scotland - Sycamore Service, page 17 of 31

18 Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Capability Scotland - Sycamore Service, page 18 of 31

19 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths We found this service to have a very good performance in relation to this statement after we sampled the following: * Observations of environment and resources. * Security procedures. * Transport arrangements. * Risk assessments. * Maintenance records. * Infection controls and preventions. * Insurance. The service is one of three services which use the premises, and therefore does not have absolute control with regards to the environment. Management and staff had taken care and consideration to creating a safe, nurturing and welcoming environment suitable to the needs of young people attending. We found the areas used within the building are large, bright and spacious and provide opportunities for young people to engage in a variety of free flow play, small group and one to one activities. We found staff were very aware of how young people respond to the various environmental factors associated with the building and had worked hard to create a pleasant environment with calm areas and appropriate resources to meet their individual needs, likes, dislikes and current interests. One young person confidently showed us around all the rooms and described the purpose of each room. He told us that he did not visit the sensory room or soft play areas, as they were for younger children. However, he was happy to show us the areas he particularly enjoyed including the games room, chill out room, large physical area and resource cupboard. In consequence, young people could make informed decisions about the resources they wished to use and staff supported them to maximise and improve opportunities to led their own learning. Access to the service was by a door entry system, with additional security key pads throughout. The service operated a sign in sign out system to register children's attendance. Visitors to the service used the same system. This helped to prevent any unauthorised people entering the service. Capability Scotland - Sycamore Service, page 19 of 31

20 Young people were supported to travel independently and to make informed decisions about routes taken and risk factors associated with road safety, people, mode of transport and finances. This approach was monitored closely and informed assessments within personal planning meetings. In addition, staff completed risk assessments for individual children are completed when the general risk assessment is not applicable e.g. where safer assistance is required. These are audited at each Health and Safety inspection. We found generic risk assessments were available to inform staffs knowledge of risks inside and outside the premises and how to minimise them contributed to ensuring everyone was safe. We have made further comments on risks management in the areas for improvement section below. The outdoor area was seen as an extension to the playrooms and had an open door which led in and out of the building providing opportunities to extend learning experiences. We saw young people independently accessing play experiences outdoors or being supported by staff to do so. Various activities were taking place throughout the day, following their interests and planned routines. A cleaner was employed to ensure the cleanliness of the premises. Through discussion and observation of practice on the day of inspection, it was evident staff were knowledgeable of and implemented good infection control practices to assist in keeping children healthy and free from infection. An online system for maintaining a log of any repairs or maintenance work that needed to be carried was in place. This allowed an audit trail to be in place detailing when the concern was first reported and any action taken. Of the sample of records of accidents and incidents we looked at, overall they were dealt with appropriately, including sharing information with the parent. The provider had appropriate insurance in place and was available for inspection. Areas for improvement The provider identified the following areas for improvement in the services self assessment: "The health and safety of service users and staff is a priority within the whole organisation." We found that some resources and other equipment appeared tired and worn. The acting manager highlighted that many of the resources were donated or second hand. One young person told us that they do not have all the balls for the pool table, so they made up their own rules. We could see some new resources were purchased Capability Scotland - Sycamore Service, page 20 of 31

21 following fund raising activities, however, we discussed further provision of resources suitable to meet the interests and needs of the young people in attendance. See recommendation 1. Quality Theme 2, Quality Statement 2. Generic risk assessments were in place and staff undertook visual risk assessments throughout the day. However, as this is a shared premise we discussed the need to communicate with other people who use the premises when a potential or actual risk is identified on a day to day basis. See recommendation 2, Quality Theme 2, Quality Statement 2. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 2 Recommendations Inspection report continued 1. The provider should review the provision of appropriate, well maintained equipment and materials to support key aspects of young people's development and learning. National Care Standards early education and childcare up to the age of 16: Standard 11 - Access to resources. Standard 2 - A safe environment. 2. The provider should review risk assessment reporting systems to ensure actions taken to reduce risk factors identified on a day to day basis are communicated effectively. National Care Standards early education and childcare up to the age of 16: Standard 2 - A safe environment. Capability Scotland - Sycamore Service, page 21 of 31

22 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 We found this service to have a very good performance in relation to this statement after we sampled children's and parents' participation methods. Management and staff used the same methods, to allow young people to participate in assessing and improving the quality of staffing, as those described in Theme 1, Statement 1. We received positive feedback from the young people present about staff. Comments included: "I do not like to bake but I made pancakes with (key worker named) yesterday and my mum and my sister said they were very good. I did not want to eat them but the (key worker named) told me I had worked hard and she was really good at baking cakes." "I like the staff they are good fun and can play basketball and they help me when I need to think." Areas for improvement The provider identified the following areas for improvement in the services self assessment: "In future we aim for customers to be able to partake in interview panels and formulate some of the questions to applicants." We discussed the use of other techniques that would allow young people, parents and carers to fully engage them in identifying and evaluating service specific improvements and achievements. See Recommendation 1, Quality Theme 1, Quality Statement 1. Capability Scotland - Sycamore Service, page 22 of 31

23 Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Capability Scotland - Sycamore Service, page 23 of 31

24 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 to have a very good performance in relation to this statement after we sampled the following: - Staff supervision and appraisal. - Staff training records. - Annual training plan. We found that the acting manager and staff team were motivated, enthusiastic and skilled in their work with young people and their families. They were professional in their manner when speaking to the young people, each other and other professionals. We found they had developed respectful relationships that promoted partnership approaches to support the learning and childcare approaches adopted through GIRFEC. As a result, young people benefited from having a consistent staff team who promoted opportunities to develop life skills to support their health, wellbeing and safety within the service and wider community. Through our observations, we saw staff that were caring and nurturing towards young people, who at times needed additional support and guidance. Children benefited from staffs appropriate use of praise and we could see they were responsive to strategies used promote an inclusive learning environment. Through effective systems for professional review and development staff were given the opportunity to reflect on practice and identify training needs. Training was then well planned to support and influence their practice and support learning opportunities and specific care for young people. Staff shared best practice within the community and with other colleagues. As a result, there was a culture of recognising and valuing staff's successes. Staff took on leadership roles in improving areas of learning and in developing aspects of the learning environment of the service. For example staff were involved in monitoring and evaluation personal plans, sharing their knowledge on the health and wellbeing needs of young people with other professionals at multi-agency meetings. These additional skills made a positive contribution on the quality of young peoples experiences and the work of the service. Staff were supported in these roles to ensure successful outcomes. Capability Scotland - Sycamore Service, page 24 of 31

25 Staff demonstrated how the services Local Operating Procedure, 'Handover Process' was used to ensure effective communication was maintained between part time and full time staff. In addition staff demonstrated their commitment to keeping abreast of current legislation, corporate policy and national and local guidance. All staff were registered with the appropriate bodies, Scottish Social Services Council (SSSC). The SSSC is the body that regulates the care workforce in Scotland and sets the standards for training and qualifications. Staff were aware of their responsibility in ensuring their registration was kept up-todate and in meeting the qualifications criteria for registration. Areas for improvement The provider identified the following areas for improvement in the services self assessment: "Continue to keep up to date with training and any changes to policies and procedures. Continue to ensure that service changes and disagreements regarding support between education staff and social care staff do not have a negative impact on the service users' experience at the service." We found that in light of the above area for improvement, changes to staffs responsibilities should be clearly defined and communicated to enable staff to make informed decisions. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Capability Scotland - Sycamore Service, page 25 of 31

26 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 We found this service to have a good performance in relation to this statement after we sampled young peoples participation methods. Management and staff used the same methods, to allow children and parents to participate in assessing and improving the quality of the management and leadership of the service as those described in Theme 1, Statement 1. Areas for improvement The provider identified the following areas for improvement in the services self assessment: "Carers to receive Capability Scotland's magazine (CHOICE) so that they are kept up to date with what is happening in the organisation. Continue to encourage parents/carers to feedback on every aspect of our service using the relevant forms such as 'Have Your Say' forms. Remind parents of our open door policy and that we will support them to submit feedback if required." We discussed the use of other techniques that would allow young people, parents and carers to fully engage them in identifying and evaluating service specific improvements and achievements. See Recommendation 1, Quality Theme 1, Quality Statement 1. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Capability Scotland - Sycamore Service, page 26 of 31

27 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 to have a good performance in relation to this statement after we sampled the following: - Quality assurance systems. - Improvement plan. - Complaints policy. Through discussions with the staff and through written information viewed it was evident that the acting manager provided leadership opportunities and was a positive role model for staff. We found this approach impacted very well on fostering the ability of staff as effective practitioners. Management and staff used a range of methods to involve young people, parents, staff and other professionals in evaluating the service. For example: consultation with children, parents and other professionals, regular staff and management meetings, visual monitoring of children's wellbeing and playroom layout, staff appraisals and reviews, quality assurance meetings with the local authority and self- assessment reports. Capability Scotland has a quality management system in place to enable staff to access and respond to information on-line. The PLAN-DO-CHECK-ACT approach forms the basis of the quality management system. In addition, an internal audit team carry out annual audits focusing on specific policies and procedures in operation within individual services and the organisation. Staff confirmed they can access quality policies via the intranet. Monthly service report are completed to enable management to audit specific operational issues including accident and incident reports, required by the Care Inspectorate. In addition, staff receive feedback on their performance through the multi-disciplinary meetings which informs future developments within the service. Areas for improvement The provider identified the following areas for improvement in the services self assessment: "Continue to regularly review the QMS and update/implement an changes accordingly. Capability Scotland - Sycamore Service, page 27 of 31

28 Continue to encourage Carers to use Having You Say forms and also highlight the importance of completing evaluations forms for the service to ensure is continues to meet their child's and their family's needs." We acknowledge that the provider had Quality Management Systems in place, however, we found missed opportunities to establish clear plans for maintaining and improving the service. We found quality assurance systems failed to show the process taken to identify and monitor service specific priorities for improvement, for example, procedures to implement GIRFEC, monitoring and evaluating service delivery including parental involvement, partnership with other agencies and leadership opportunities for staff. See Recommendation 1, Quality Theme 4, Quality Statement 4. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. The provider should implement service specific quality assurance systems to show the process taken to monitor service achievements and priorities for improvement. Staff will have clear plans for maintaining and improving the service. National Care Standards early education and childcare up to the age of 16: Standard 13 - Improving the service. Capability Scotland - Sycamore Service, page 28 of 31

29 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 the Care Inspectorate re-grading a Quality Statement within the Quality of Management and Leadership Theme (or for childminders, Quality of Staffing Theme) as unsatisfactory (1). This will result in the Quality Theme being re-graded as unsatisfactory (1). Capability Scotland - Sycamore Service, page 29 of 31

30 5 Summary of grades Quality of Care and Support Good Statement 1 Statement Good 5 - Very Good Quality of Environment Good Statement 1 Statement Good 4 - Good Quality of Staffing Good Statement 1 Statement Good 5 - Very Good Quality of Management and Leadership Good Statement 1 Statement Good 4 - Good 6 Inspection and grading history Date Type Gradings 2 Aug 2011 Announced (Short Notice) Care and support Environment Staffing Management and Leadership 5 - Very Good Not Assessed 5 - Very Good 5 - Very Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Capability Scotland - Sycamore Service, page 30 of 31

31 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: Web: Capability Scotland - Sycamore Service, page 31 of 31

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