The Richmond Fellowship Scotland - East Renfrewshire & South Lanarkshire 2 Housing Support Service Ground Floor 9 Cambuslang Road Clydesmill Industrial Estate Cambuslang G32 8NB Telephone: 0141 643 6513
Inspected by: Jim Brannigan Type of inspection: Unannounced Inspection completed on: 28 September 2012 Inspection report continued
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 18 5 Summary of grades 19 6 Inspection and grading history 19
Service provided by: The Richmond Fellowship Scotland Limited
Service provider number: SP2004006282
Care service number: CS2004061337
Contact details for the inspector who inspected this service: Jim Brannigan Telephone 01698 897800 Email [email protected]
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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 Staffing 5 Very Good Quality of Management and Leadership 5 Very Good
What the service does well The service continued to have a strong commitment to consultation and participation. There were good examples of the action that was being taken to ensure improved outcomes for service users.
What the service could do better The service could improve the consistency and quality of information in staff files.
The service is very good at gathering information. However, the service could improve how it shows what action it has taken from this information to develop the service.
The service could improve the information on how it engages with people who do not complete in-house questionnaires.
What the service has done since the last inspection The service is introducing a new care plan format and we look forward to seeing this at future inspections.
Conclusion The service continues to provide a very good standard of care and support. The majority of responses we received confirmed that service users were overall very happy with their support and had good relations with staff.
The Richmond Fellowship Scotland - East Renfrewshire & South Lanarkshire 2, page 3 of Inspection report continued Who did this inspection Jim Brannigan
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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. 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 1 April 2011 this service continued its registration under the new body, SCSWIS.
Information in relation to all care services is available on our website at www.careinspectorate.com.
The service provides housing support and care at home to 435 individuals with a learning disability or mental health problems who live in East Renfrewshire and South Lanarkshire. The service users receive different levels of support depending on their assessed needs, from several hours per week to 24 hour support. Staff are based in two area offices in East Renfrewshire and South Lanarkshire. The service's mission statement is: " We believe in and work towards promoting
Choice Community Involvement Helpful staff Opportunities In control of your own life Care Empowerment"
The Care Inspectorate will award grades for services based on findings of inspections. Grades for this service may change after this inspection if we have to take enforcement action to make the service improve, or if we uphold or partially uphold a complaint that we investigate.
The history of grades which services have been awarded is available on our website. You can find the most up-to-date grades for this service by visiting our website, by calling us on 0845 600 9527 or visiting one of our offices.
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.
The Richmond Fellowship Scotland - East Renfrewshire & South Lanarkshire 2, page 5 of Inspection report continued - 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.
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 Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 5 - Very Good
This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection.
Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website www.careinspectorate.com or by calling us on 0845 600 9527 or visiting one of our offices.
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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 compiled the report following an unannounced inspection. The inspection was carried out by Care Inspector Jim Brannigan. The inspection that took place between 10.15 am and 16.50 pm on 27 September 2012 and 10.00 am and 16.45 pm on 28 September 2012.
As requested by us, the provider sent us an annual return. The provider also sent us a self assessment form.
In this inspection we gathered evidence from various sources, including the relevant sections of policies, procedures, records and other documents: Evidence from the service's most recent self assessment;
Personal plans of people who use the service;
In-house questionnaires; analysis of returned Care Inspectorate questionnaires;
Newsletters;
Policies and procedures;
Questionnaires that had been requested, filled in and returned to the care service from people who use the service, their relatives or advocates, and staff members;
Discussions with various people, including: - the manager - four care 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
The Richmond Fellowship Scotland - East Renfrewshire & South Lanarkshire 2, page 7 of Inspection report continued themes and statements.
Details of what we found are in Section 3: The inspection
Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement.
Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at www.firelawscotland.org
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What the service has done to meet any requirements we made at our last inspection
The requirement undefined
What the service did to meet the requirement
The requirement is:
What the service has done to meet any recommendations we made at our last inspection Outstanding recommendations are commented on under the relevant Quality Themes and Statements.
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 development and any changes they had planned. The service provider told us how the people who used the care service had taken part in the self assessment process.
The Richmond Fellowship Scotland - East Renfrewshire & South Lanarkshire 2, page 9 of Inspection report continued Taking the views of people using the care service into account We sent out questionnaires to people who use the service and their relatives and carers. When asked about the overall quality they receive in this service the great majority of people who replied said that they strongly agreed with the statement "Overall, I am happy with the quality of care and support this service gives me." No-one who replied disagreed with this statement.
We received the following additional comments in the questionnaires
"I really like the richmond fellowship because they always come in to support me. I like the staff and get on well with the staff."
"I am grateful for the support I receive from the service as I don't have much family or friends."
"The groups are a great idea. It's a break away and a time to relax and take part in fun activities and outings."
"The service is good, friendly and there are nice people in the team."
Taking carers' views into account Carers include parents, guardians, relatives, friends and advocates. They do not include care staff. We sent out questionnaires to people who use the service and their relatives and carers.
The vast majority of people who replied said that they strongly agreed or agreed with the statement "Overall, I am happy with the quality of care and support this service gives me." No-one who replied disagreed with this statement. We received the following additional comments in the returned questionnaires:
"Have been using the service for a short time and receive part time support at the moment."
"Very happy with the service"
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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 undefined Areas for improvement The service is maintaining current very good standards and continuing to improve. The care service should continue to monitor and maintain the standards of quality. They should ensure they are rigorous in identifying any areas for improvement and implementing action plans to address these.
We thought that the quality of the questions in the 'How well are we doing' survey could be improved and expanded.
The provider did not clearly demonstrate how the views of the nineteen service users who did not respond to the 'How well are we doing' survey were being collated.
We did not see any information in the 'Executive Summary' about what action the service were taking to address the issues raised by people who responded negatively to the service e.g.
1.4% said 'not often or never' when asked " Do we give you the right support" 1.2% said 'not often or never' when asked " Do we give you all the choices you want".
We thought it would be helpful if the service had a clear action plan on how it proposes to address issues raised through the participation process. (see recommendation 1 )
The Richmond Fellowship Scotland - East Renfrewshire & South Lanarkshire 2, page 11 of Inspection report continued Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1
Recommendations 1. The service should have clear action plans on how it proposes to address issues raised through the participation process. (National Care Standards, Care at Home, Standard 4: Management and Staffing, National Care Standards, Housing Support, Standard 3: Management and Staffing).
Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths We found this service was performing at a very good level in the areas covered by this statement. The care service ensured that people's health and wellbeing needs were being met in several ways: These included:
• we thought that the care plans which we saw had very good information about how service users' health care needs should be met; e.g.communication,administration of particular medication,moving and handling techniques. • we saw very good information on how individual medication should be administered from health professionals;e.g.protocols for the administration of diazepam and midazolam buccal • we saw very good photographic and written narrative in place from the Community Learning Disability Team Physiotherapist on how to to move service users correctly; • we saw very good evidence from the plans that advice and assistance continued to be obtained from the community medical and nursing services, as required e.g. visits to continence nurse,chiropodist,dietician; • we saw that regular reviews were being carried out; • we saw some good examples of people taking part in activities which promoted self worth, and psychological well being e.g. computers,keyboard,drama; • we saw good information on how to communicate with one service user who had communicate difficulties.
Areas for improvement The service is maintaining current very good standards and continuing to improve.
The Richmond Fellowship Scotland - East Renfrewshire & South Lanarkshire 2, page 12 of Inspection report continued The provider should continue to monitor and maintain the standards of quality. They should ensure they are rigorous in identifying any areas for improvement and implementing action plans to address these.
We thought that some of the care plans we saw were bulky, repetitive in content in places, and could be difficult to follow. Personal plans were not fully person centred;e.g. '24 hour support in all aspects of care'.
However we acknowledge that the service is introducing a new care plan format which aims to address these issues and we look forward to seeing this at future inspections.
We identified some areas for improvement around the recording of the administration of medication. For example we saw hand written instructions on how to administer medication that were not signed, dated and with no professional designation. Some of the information we saw in this area was repetitive and it was not clear which instruction was current. The service stated that the systems of recording and administering medication were being reviewed. (see recommendation 1 )
Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1
Recommendations 1. The service should amend the system for recording and administration of medication.
We signposted the service to Royal Pharmaceutical Society of Great Britain 'The Handling of Medicines in Social Care.2007, RPSGB' and "Guidance about medication personal plans, review, monitoring and record keeping in residential care services. 2012. Care Inspectorate", (accessible from www.careinspectorate.com).
(National Care Standards, Care at Home, Standard 7: Keeping Well-Healthcare, Standard: Keeping Well-Medication).
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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 comments under Quality Statement 1.1 Areas for improvement See comments under Quality Statement 1.1
Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0
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 at a very good level in the areas covered by this statement.
We saw that the service had a good induction programme for new staff and we saw good examples in the staff files that we looked at of regular supervision taking place. These were recorded and signed by staff and management.
We thought that the staff appraisal information that we looked at was very good. The information was detailed and informative with discussion on training completed and future learning objectives.
Some staff had an 'Individual Learning and Development' plan. Staff indicated in completed Care Inspectorate questionnaires that regular supervision took place.
The Richmond Fellowship Scotland - East Renfrewshire & South Lanarkshire 2, page 14 of Inspection report continued Staff had a good knowledge of whistleblowing, confidentiality and adult protection. Staff were familiar with the National Care Standards and the Scottish Social Services Council (SSSC) Codes of Practice.
We saw evidence that some staff had obtained a Scottish Vocational Qualification (SVQ) level II and/or III in Health and Social Care.
There was a rolling programme in place for staff to achieve an SVQ Level II in Health and Social Care, equivalent or above;
The provider had a learning and development policy in place and the Richmond Fellowship was an approved SVQ centre;
The majority of staff indicated in Care Inspectorate questionnaires that they had access to training opportunities in the last 12 months and that their training needs were being met. Areas for improvement The service is maintaining current very good standards and continuing to improve. The care service should continue to monitor and maintain the standards of quality. They should ensure they are rigorous in identifying any areas for improvement and implementing action plans to address these.
A small number of the staff files that we saw did not have an individual training record, individual training plan and did not have copies of all certificates of training attended. (see Recommendation 1 ) We signposted the service to the Scottish Social Services Council (SSSC) publication, 'The Framework for Continuous Learning in Social Services' for information and guidance.
Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1
Recommendations 1. The manager should ensure that all staff have an accurate and up to date individual training record, individual training plan and individual personal development plan. Copies of any training certificates attended/awarded should be held in individual files. (National Care Standards, Care At Home - Standard 4: Management and Staffing Arrangements, National Care Standards, Housing Support Services - Standard 3: Management and Staffing Arrangements)
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Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 5 - Very Good
Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths See comments under Quality Statement 1.1 Areas for improvement See comments under Quality Statement 1.1
Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0
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 at a very good level in the areas covered by this statement. We concluded this after we saw:
• staff receive regular 1:1 supervision ; • staff have an annual appraisal with some staff having an individual development plan; • we saw that management meetings are held every 3 to 4 weeks; • team meetings were held monthly; • we saw that the service gathered information from staff development plans, service users questionnaires and open days to help improve the service • we saw that the service carries out internal audits using TRFS "national evaluation tools". This was completed every two years and was due to be completed this year,2012; • TRFS holds an award for investors in people (IIP);
The Richmond Fellowship Scotland - East Renfrewshire & South Lanarkshire 2, page 16 of Inspection report continued • the service is affiliated to the European Foundation for Quality Management (EFQM). TRFS has renamed this to "Quest For Quality." • we were advised that the service was in the process of writing its submission to the Scottish Government for the 'Committed to Excellence Award'; • Care Inspectorate reports were collated at TRFS head office. ctioA n plans were monitored through head office to ensure they were met; • the service was aware of the services responsibility to report to Scottish Social Services Council (SSSC) any staff dismissed on the grounds of misconduct; • the service was aware that the service must provide SSSC information it may require about members of staff; • we saw that the service had copies of the Care Inspectorate Notification Guidance and the service knew of their responsibility to notify the Care Inspectorate of matters of misconduct including theft; • we saw that the service had an appropriate complaints procedure; • the service had a process to advise service users if their were any changes to their care package.
Areas for improvement The service is maintaining very good standards and continuing to strive for further improvement. The provider should continue to monitor and maintain the standards of quality. They should ensure they are rigorous in identifying any areas for improvement and implementing action plans to address these.
The service could improve how it records what action it has taken to address issues raised. (see recommendation 1)
Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1
Recommendations 1. The manager should ensure that clear records are in place to respond to the service evaluations, these are clearly dated and record what action has been taken to address any issues identified. ( National Care Standards, Care at Home - Standard 11: Expressing Your Views, National Care Standards, Housing Support Services - Standard 8: Expressing Your Views )
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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).
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5 Summary of grades
Quality of Care and Support - 5 - Very Good
Statement 1 5 - Very Good
Statement 3 5 - Very Good
Quality of Staffing - 5 - eryV Good
Statement 1 5 - Very Good
Statement 3 5 - Very Good
Quality of Management and Leadership - 5 - Very Good
Statement 1 5 - Very Good
Statement 4 5 - Very Good
6 Inspection and grading history
Date Type Gradings
16 Jun 2010 Announced Care and support 5 - Very Good Staffing Not Assessed Management and Leadership 5 - Very Good
17 Jul 2009 Announced Care and support 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good
25 Aug 2008 Announced Care and support 5 - Very Good Staffing 5 - Very 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.
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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 0845 600 9527.
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: www.careinspectorate.com or by telephoning 0845 600 9527.
Translations and alternative formats This inspection report is available in other languages and formats on request.
Telephone: 0845 600 9527 Email: [email protected] Web: www.careinspectorate.com
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