Burns Day Service Support Service Without Care at Home 73 Burns Crescent Girdle Toll Irvine KA11 1AS Telephone: 01294 272525
Inspected by: Mina Cassidy Type of inspection: Unannounced Inspection completed on: 23 July 2013 Inspection report continued
Contents
Page No Summary 3 1 About the service we inspected 6 2 How we inspected this service 7 3 The inspection 11 4 Other information 25 5 Summary of grades 26 6 Inspection and grading history 26
Service provided by: North Ayrshire Council
Service provider number: SP2003003327
Care service number: CS2003034607
Contact details for the inspector who inspected this service: Mina Cassidy Telephone 01294 323920 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 4 Good Quality of Environment 4 Good Quality of Staffing 4 Good Quality of Management and Leadership 4 Good
What the service does well Burns Day Care service is provided from purpose built premises which are equipped and furnished to a high standard.
The service continues to offer a friendly and warm environment where service users can meet each other and enjoy a range of activities and entertainment. Service users continued to tell us how much they looked forward to attending the service and also told us about the outings and activities they had enjoyed. Service users' comments about staff continue to be very positive with comments such as 'they are just brilliant', 'always able to cheer up your day'.
Service users had been involved in the recruitment process for the employment of new staff.
We saw that staff continued to work well as a team. Staff knew service users very well. They knew the support service users needed and their support arrangements at home. Staff knew the people and things that were important in service users' lives.
The service had continued to develop and improve the methods used to encourage the involvement and participation of service users and their families. This included questionnaires, meetings, daily diaries and daily consultation about the quality of food served.
Staff had compiled a number of resource folders on specific subjects to facilitate and
Burns Day Service, page 3 of 28 Inspection report continued encourage service users' participation in special interest clubs such as; the camera club and the computer club. Service users continued to be involved in compiling photograph albums of activities and events,
The service continued to work well with other professionals in social work and health and ensured a quick response to any changes in a service user's needs.
What the service could do better Following this inspection the Care Inspectorate has highlighted areas for improvement which are:
The quality of Care planning had improved. However, there were still some instances where care plans did not reflect the findings of risk assessments and dependency assessments. Although the frequency of staff supervision had improved there was still some instances when it did not take place at the frequency stated in the provider's supervision policy. The provider should compile a training plan specifically orf the service which takes into account the aims and objectives of the service, the annual mandatory training and up to date practice guidance to meet the needs of service users. The service should evidence how service users are involved in the self assessment process for future inspections.
What the service has done since the last inspection The provider has continued to develop and improve the ways that service users can comment and express their views on the quality of service. The provider has introduced carer events which have been very successful and provides another way for carers to be involved in the development of the service. Two members of staff now had delegated responsibility for service user and carer engagement. The provider now ensures that 6 monthly care reviews are taking place. The frequency of staff supervision has improved. The quality surveys completed by service users and carers in 2012 have now been evaluated by an independent source and an action plan was compiled. The surveys completed during June and July 2013 have been submitted for evaluation. The staffing issues identified in the last report have been resolved.
Conclusion North Ayrshire Council provides a day care service offering a good range of activities and stimulation for service users. Service users continue to tell us how much they look forward to their visits to the service and how crucial it is to them. The service provides good outcomes for service users.
Burns Day Service, page 4 of 28 Inspection report continued Who did this inspection Mina Cassidy
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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. Information in relation to all care services is available on our website at www.scswis.com
The Care Inspectorate will award grades for services based on findings of inspections. Grades for this care service may change after this inspection due to other regulatory activity; for example, if we have to take enforcement action to make the service improve, or if we uphold or partially uphold a complaint we investigate.
If we are concerned about some aspect of a service, or think it could do more to improve its service, we may make a requirement or a recommendation.
* 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 Reform (Scotland) Act 2010 and Regulations or Orders made under the Act or conditions of registration. Where there are breaches of Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Care Inspectorate. Burns Day Care Service is owned and managed by North Ayrshire Council and is located in Girdle Toll in Irvine. The service is provided in purpose built premises and accommodates up to 16 frail elderly and 14 people with dementia each day.
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
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 This unannounced inspection took place on the 23rd July was carries out by 2013 by Mina Cassidy Care Inspector. During the inspection we carried out the examined the following records and documents and spoke with service users and staff.
* Participation Strategy * Personal plans * Service user reviews * Service User (SU) Questionnaires, Analysis and Action Plan * Accident and Incident records * Newsletters * Minutes of service users meetings * Training programme * Training records * Supervision records * Personal development reviews * Activities plan and records * Minutes of staff meetings * H&S audits * COSHH records * Gas safety certificate * Maintenance contracts - gas and equipment * Cleaning and food hygiene records * Environmental Risk Ass * Environmental Health Report We spoke with the following people: Service users (10) Senior Day Care Officer Day Care Assistants (3) Manager We looked at the environment and observed staff practice.
Burns Day Service, page 7 of 28 Inspection report continued Grading the service against quality themes and statements We inspect and grade elements of care that we call 'quality themes'. For example, one of the quality themes we might look at is 'Quality of care and support'. Under each quality theme are 'quality statements' which describe what a service should be doing well for that theme. We grade how the service performs against the quality themes and statements.
Details of what we found are in Section 3: The inspection
Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement.
Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at www.firelawscotland.org
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What the service has done to meet any requirements we made at our last inspection
The requirement The provider must ensure that formal reviews take place at least 6 monthly. This is to comply: Public Services Reform (Scotland) Act 2010 SSI210 Regulation 5 (2) (b) (iii). Timescale for implementation 3 months from the publication of this report.
What the service did to meet the requirement See Quality Theme 1 Statement 1
The requirement is: Met
The requirement The provider must ensure that the quality of care planning is improved to clearly show service users' needs and how these needs will be met. This is in order to comply with: This is in order to comply with SSI 2011/210 Regulation 4 (1) (a) Welfare of Service users. Timescale for implementation: 3 months from the date of publication of this report.
What the service did to meet the requirement See Quality Theme 1 Statement 3
The requirement is: Met
What the service has done to meet any recommendations we made at our last inspection The Action taken on the recommendations made in the last inspection report are detailed in each relevant quality statement
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
Burns Day Service, page 9 of 28 Inspection report continued 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. 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, completed in full noting strengths and areas for improvement.
Taking the views of people using the care service into account We spoke to 10 service users in two groups. Service users continued to speak very positively about their experience of the service. Some told us how important the service was to them to ensure they did not become isolated and lonely. They confirmed that they had been involved in the recruitment process for new staff and how they felt this was a very important thing to do and how it made them feel valued and listened to. They told us food was very good and that they were always asked to give their views on the quality of food. They told us that if there had been issues they were able to be very open about it and the issues were 'sorted out'. Service users told us about the activities available to them some said they particularly liked the carpet bowls and the exercises in the morning. They told us about some of the outings they had enjoyed in the recent good weather and how they liked getting out in the bus to look at the scenery, even when the weather was not good. They told us that there were no problems with the transport.
Some said they enjoyed the journey into the centre in the morning as it was like 'a wee trip in the bus' and an opportunity 'to see the scenery and what was going on.' Service users told us they were involved in expressing their views on the quality of the service and that they had no problems in telling staff if there were any issues. We asked service users if there was anything they could suggest to make things even better and they told us that they couldn't think of anything.
We received five questionnaires from service users. All answers to the questions asked were positive with no negative responses made. Three people indicated that they strongly agreed with the statement 'Overall I am happy with the quality of care the service gives me'. Two indicated they agreed with this statement.
Taking carers' views into account We received one questionnaire back from a relative. The relative made very positive responses to all the questions asked and selected 'Strongly Agree' to the question; 'Overall I am very happy with the quality of 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: 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 This Quality Statement was graded 4 - Good in the last inspection report of 14th August 2012. We sampled evidence against this statement and considered the progress made to meet the requirements and recommendations made in the last report and found the service had improved performance and the statement was graded 5 - Very Good.
We concluded this from discussions with the senior day care worker, service users, and staff. Other sampled evidence included;
Participation strategy Personal plans Service user reviews Newsletters Minutes of service user's meetings Evidence of carer events Activity survey
The service continued to develop and improve the methods to encourage the involvement and participation of service users and carers which reflected the principles and aims outlined in North Ayrshire Council's participation Strategy (From Consultation to Participation - a Strategy for Service Users and Family Carers in North Ayrshire).
Service users were encouraged to express their views about the quality of the service during informal day to day discussions and more formally during service user
Burns Day Service, page 11 of 28 Inspection report continued meetings, care reviews and annual quality surveys.
Service user meetings continued to be carried out on a rolling programme throughout the week ensuring that every service user had the opportunity to attend. Service users continued to be encouraged to add to the meeting agenda. We saw from minutes and action points that there were discussions on the choice of activities, outings and events. Service users also had the opportunity to discuss the National Care Standards and give their views on how they considered the service to be meeting these standards. Service users continued to be encouraged to give daily feedback on the quality of food which were then passed on to catering staff.
We could see that service users had been involved in compiling their care plan and pen picture.
Although a daily activity schedule was in place we saw that service users continued to be offered choices on how they wished to spend their time in the service. The service users told us they were kept informed about what was happening in the service. Information about how to make a complaint was available to service users' information leaflets and displayed on the notice board. Information was also available on how make a complaint via the Care Inspectorate.
The service continued to produce a quarterly news letter providing information about events and activities which had taken place. This included peoples' views on their success and also planned future events such as visiting entertainers and outings.
A 'You Said We Did' board was situated in the foyer, showing the views expressed by service users and carers in surveys, meetings and informal discussions and the action taken.
The service had introduced regular carer events which had proved successful. This included a range of speakers to provide carers with relevant and interesting information and also allowed carers to express their views on the quality of the service. The service continued to arrange special events for carer's week.
Two members of staff had specific delegated espor nsibility for service users and carer participation, which included planning and organising care reviews.
The following requirements and recommendations made in the last inspection report had been met;
The provider must ensure that formal reviews take place at least 6 monthly. This is to comply: Public Services Reform (Scotland) Act 2010 SSI210 Regulation 5 (2) (b) (iii).
The provider now ensured that 6 monthly care reviews were carried out for all service
Burns Day Service, page 12 of 28 Inspection report continued users. Service users and carers were given advance notice of planned reviews the system used to track the frequency sand timing of reviews had been improved.
All service users should be provided with a service agreement, signed and dated by both parties, National Care Standards Support services. Standard 3; Your Legal Rights.
Service user agreements were now in place for all service users all of which were signed and dated by both parties.
The provider should ensure that all quality surveys completed by service users are duly evaluated with subsequent action plans. National Care Standards: Support services. Standard 12; Expressing your views
The provider now had arrangements in place to ensure that completed quality surveys were evaluated and an action plan put in place. The quality surveys were evaluated out with the service. The quality surveys completed in June, July 2013 had been submitted for evaluation.
The provider had also arranged for a local voluntary advocacy group to attend the centre and assist service users, where required, with the completion of surveys. Areas for improvement The service should continue to develop current good practice.
Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0
Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths This Quality Statement was graded 4 - Good in the last inspection report of 14th August 2012. We sampled evidence against this statement and considered the progress requirement made in the last report and found the service had maintained performance and the grade remained 4 - Good.
We concluded this from discussions with the senior day care officer, service users, and staff. Other sampled evidence included;
Personal plans Service user reviews Individual Risk Assessments
Burns Day Service, page 13 of 28 Inspection report continued Dependency Assessments Individual preferences and interests Activity records Daily diaries
As we found in the last inspection, an assessment of service users care needs were carried out at commencement of the service. The initial assessment was carried out for some service users during a home visit. Other service users and carers made a visit to the service for the initial assessment. A care plan was compiled showing how individuals' needs should be met. Service users, and if appropriate, their relative/carer was involved in this process.
Records were maintained showing how each service user had spent their day at the service, including any activities they had participated in.
The service used North Ayrshire Council's risk assessment tool to assess risk such as falls and slips, wheelchair use, going on outings and travelling on the bus in addition to any other identified risk elatedr to meeting service users' needs. Separate moving and handling risk assessments were also available.
A key worker system was in place. Staff demonstrated through discussion that they knew service users well including their specific care needs and how these should be met.
We saw that service users continued to be referred to other services and professionals when required, such as Chiropodist, Dentist and Optician, who all visited the service.
We saw that service users continued to be assisted with personal care in a discreet manner ensuring their privacy and dignity was respected at all times.
Care plans included details of any dietary requirement and food preferences. Service users told us they were happy with the quality of the food. We saw that service users had been asked daily about the quality of food and that their views were fed into a catering meeting.
Service users had enjoyed a good selection of outings, which included trips to the coast such as Saltcoats and Largs for ice cream. The service held regular 'cinema days' with the films chosen by the service users and fish and chip days. Service users were asked on a daily basis to choose from a range of activities on offer. Service users were encouraged to move freely between Heather and Bracken Units, to choose preferred activities and sitting areas and were not limited to a specific allocated Unit.
There were a number of photographs available showing service users enjoying activities, entertainment and outings. Service users continued to be involved in compiling photograph albums and books showing internal and external activities.
Burns Day Service, page 14 of 28 Inspection report continued
The service continued to achieved good outcomes for the people using the service. The service did meet the aims and objective to alleviate social isolation, build confidence and to provide an essential part of the overall care packages that supported people to live in their own homes for as long as possible.
The following requirement made in the last inspection report was met;
The provider must ensure that the quality of care planning is improved to clearly show service users' needs and how these needs will be met. This is in order to comply with: This is in order to comply with SSI 2011/210 Regulation 4 (1) (a) Welfare of Service users.
We found good improvements had been made to the quality of assessments and care planning and therefore considered this requirement to be met. However, we did see the need for further improvements and have made a recommendation to this effect. Areas for improvement The quality of assessments and care plans had generally improved. We found they were better structured offering clearer direction to staff on how individuals' assessed needs should be met. However, we found areas of assessed need or risk which had not been included in individual's care plan.
(See recommendation 1 for this quality statement)
Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1
Recommendations 1. The provider should ensure that all areas of assessed need or risk are reflected in individual's care plans. National Care Standards Support Services. Standard 4: Support arrangements
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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 The areas of strengths outlined in Quality Theme 1 Statement 1 are also relevant to this quality statement. Areas for improvement The areas for improvement outlined in Quality Theme 1 Statement 1 are also relevant to this quality statement.
Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0
Statement 2 We make sure that the environment is safe and service users are protected. Service strengths This Quality Statement was graded 5 - Very Good in the last inspection report of 14th August 2012. We sampled evidence against this statement and considered the progress requirement made in the last report and found the service had maintained performance and the grade remained 5 - Very Good.
We concluded this from discussions with the senior day care officer, service users, and staff. Other sampled evidence included;
Care plans and risk assessments Maintenance records Generic and COSHH Risk Assessments Maintenance contracts, certificates and records Health and safety Checks. Health and safety relating training System used to record fundraising and donated funds.
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As stated in the last inspection report the provider had a comprehensive range of health and safety policies and procedures accessible to staff.
Staff continued to complete Health and Safety focused training such as; moving and handling, infection control, health and safety and fire safety. Staff had also completed training in Adult Support and Protection.
We re-examined service contracts for equipment and utilities and found the following were in place and maintenance continued to be carried out at the required intervals for the following; * fire safety equipment * emergency lighting * lifting equipment and slings * Legionella testing * gas safety certificate
In house safety checks of equipment continued to be up to date and well ordered.
A system of accident and incident reporting was maintained.
General risk assessments had been completed to support staff in the operation of a range of equipment in the care home and tasks related to their role. Risk assessments for the Control of Substances Hazardous to Health (COSHH) were also available.
People visiting the care home were required to ring the bell to gain entry. The door was appropriately secured and all visitors had to sign in and out.
The following recommendation made in the last inspection report had been met;
The provider should implement a process which clearly tracks service users' medication in and out of the service. National Care Standards Support Services. Standard 2: Management and staffing arrangements.
The provider had reviewed the policy and procedure for the management of service users medication to include the need to record the medication being retuned to service users and the end of each day care session. We examine records and found this was consistently done. Areas for improvement We noted from records and from the labels attached to items of electrical equipment that some portable appliances had not been safety checked for some period of time. The provider should ensure that portable appliances are checked taking into account risk assessments and in accordance with up to date guidance.
Burns Day Service, page 17 of 28 Inspection report continued (See recommendation 1 for this quality statement)
Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1
Recommendations 1. The provider should ensure that portable appliances are safety checked at the required intervals taking into account risk assessments and up to date health and safety guidance. National Care Standards Support Services. Standard 2: Management and staffing arrangements.
Statement 3 The environment allows service users to have as positive a quality of life as possible. Service strengths Adequate. We concluded this from discussions with the manager, senior day care officer and our observations.
The service is located in purpose built premises which has 2 separate units (Bracken and Heather). Both units had a sitting room with a kitchen/craft area and separate dining rooms. There were alternative sitting areas including a conservatory with doors leading to the garden. There are also toilets and showering facilities in each unit.
The garden had lawns and a patio area with garden furniture providing attractive outdoor space for service users.
The centre was furnished and decorated to a high standard. Service users told us that they were very happy with the quality of the environment and the facilities available to them. Areas for improvement We discussed with the manager and the senior day care officer the lack of space currently available in the assisted toilet/shower room to appropriately assist people with personal care who require to use a wheelchair and hoist. The lack of space meant that service users in a wheelchair had to be transferred to the hoist in the corridor before being assisted into the toilet. The service had two assisted toilet/ shower rooms where the showers are rarely used. We discussed the possibility of removing one of the showers and possibly re-arranging the sanitary ware to create the space required to support service users with their personal care in a way which protected their privacy and dignity. The grade awarded to this quality statement is influenced by this issue. The provider must ensure that appropriate toilet facilities are available for service users who require the use of a wheelchair and hoist which protects their privacy and dignity.
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(See requirement 1 for this quality statement)
We noted that due to a lack of alternative space staff had to take their breaks in the busy office. eW discussed with the manager and the senior day care officer other potential options where staff could have a designated staff area. We discussed the use of an attached office which could be accessed externally from the day care building. The manager and senior day care officer stated that the eaf sibility of this option would be discussed with senior managers and day care staff.
Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 0
Requirements 1. The provider must ensure that appropriate toilet facilities are available for service users who require the use of a wheelchair and hoist which protects their privacy and dignity. This is in order to comply with; SSI 2011/210 Regulation SSI 2011/210 Regulation 10 (2) (a) Fitness of premises and Regulation 4 (1) (a) Welfare of Service users.
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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 The areas of strengths outlined in Quality Theme 1 Statement 1 are also relevant to this quality statement. Areas for improvement The areas for improvement outlined in Quality Theme 1 Statement 1 are also relevant to this quality statement.
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 This Quality Statement was graded 4 - Good in the last inspection report of 14th August 2012. We sampled evidence against this statement and considered the progress made to meet the recommendations in the last report and found the service had maintained performance and the grade remained 4 - Good.
We concluded this from discussions with the senior day care officer, service users, and staff. Other sampled evidence included;
Training records Supervision records Staff meetings Observation of practice
North Ayrshire Council had a comprehensive range of policies and procedures
Burns Day Service, page 20 of 28 Inspection report continued available to support staff in their role. This included policies in training and development.
Staff continued to tell us they had a supportive working environment with good communication between each another and senior staff. We observed staff working well together.
Staff had knowledge of the National Care Standards and the Scottish Social Services codes of practice and how these informed their practice. We found that staff were motivated and enthusiastic about the work they did.
Training records showed that staff had accessed training in areas such as; moving and handling, fire safety, food hygiene, risk assessment, and ASIST and CALMS.
Staff meetings continued to take place at monthly intervals in addition to short daily planning meetings. The minutes of meetings showed that information was provided about corporate and service wide developments, including reviews of policies and procedures. Staff discussed service users' needs and shared ideas and suggestions on how to continually improve the service.
The following recommendations made in the last inspection report had been met.
Staff supervision should take place on a regular basis and in line with the providers own policy and procedure. National Care Standard Support Services. Standard 2: Management and Staffing arrangements.
The frequency of staff supervision had improved since the last inspection. Staff told us that they received supervision at approximately two monthly intervals. Staff also stated that the senior day care officer was approachable and available to provide support whenever required. We noted from supervision records that although the overall frequency of supervision had improved there were still a small number of occasions when the frequency was in excess of two months. The provider should be aware of this and ensure that the schedule of planned supervision is met.
The provider should ensure that all staff access appropriate Dementia training which reflects current best practice. National Care Standard Support Services. Standard 2: Management and Staffing arrangements
We noted from staff training records that all care staff had completed dementia awareness training. The senior day care officer also informed us of the provider's intention to ensure that staff complete training to at least 'skilled' level of the Promoting Excellence: A framework for all health and social care services staff working with people with Dementia, their families and carers. (June 2011)
Burns Day Service, page 21 of 28 Inspection report continued Areas for improvement The following recommendation made in the last inspection report had not been met;
The provider should compile a training plan for the service which takes into account the aims and objectives of the service, the needs of service users and the training and development needs of individual staff. National Care Standard Support Services. Standard 2: Management and Staffing arrangements.
There was a training log available showing the training staff had completed and the training staff had been nominated to attend in the future. There were also individual training plans in place as part of North Ayrshire Council's annual Personal Performance Development system. However, there was no specific service training plan based on the aims and objectives of the service, annual mandatory training, the needs of service users, the training and development needs of staff and up to date practice guidance.
(See recommendation 1 for this quality statement)
Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0
Recommendations 1. The provider should compile a training plan for the service which takes into account the aims and objectives of the service, the needs of service users and the training and development needs of individual staff and up to date practice guidance. National Care Standard Support Services. Standard 2: Management and staffing arrangements
Burns Day Service, page 22 of 28 Inspection report continued
Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 4 - Good
Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths The areas of strengths outlined in Quality Theme 1 Statement 1 are also relevant to this quality statement. Areas for improvement The areas for improvement outlined in Quality Theme 1 Statement 1 are also relevant to this quality statement.
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 This Quality Statement was graded 3 - Adequate in the last inspection report of 14th August 2012. We sampled evidence against this statement and considered the progress made to meet the requirements and recommendations made in the last report and found the service had improved performance and the statement was graded 4 - Good.
We concluded this from discussions with the manager, service users, relatives and staff. Other sampled evidence included;
Quality assurance surveys Service user and relative meetings Health and safety and environmental checks Complaint policy Care plan audits
Burns Day Service, page 23 of 28 Inspection report continued Monitoring systems
The consultation methods the service had developed such as questionnaires, service users meetings, carers' week and including consultation with staff and other stakeholders informed quality assurance systems.
An independent voluntary organisation attended the service to support them to express their views on the quality of the service.
We could see that the service provided feedback to service users and carers about any suggestions that had been made in the 'you said we did' board, the action to be taken and the reasons explained if ideas could not be progressed at that time.
The service carried out 6 monthly Safety Reports and good systems were in place to ensure that maintenance issues were reported and addressed in a suitable timescale.
Service users were informed about the provider's complaints procedures in the service leaflet and displayed in notice boards in the service. No complaints had been made to the service.
The senior day care officer had introduced a system of care plan audits to ensure that information was up-dated appropriately and that assessment tools and documentation were completed. Areas for improvement The provider should evidence how service users are involved in the self assessment process.
The provider should also continue to develop and improve quality assurance processes.
Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0
Burns Day Service, page 24 of 28 Inspection report continued
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).
Burns Day Service, page 25 of 28 Inspection report continued
5 Summary of grades
Quality of Care and Support - 4 - Good
Statement 1 5 - Very Good
Statement 3 4 - Good
Quality of Environment - 4 - Good
Statement 1 5 - Very Good
Statement 2 5 - Very Good
Statement 3 3 - Adequate
Quality of Staffing - 4 - Good
Statement 1 5 - Very Good
Statement 3 4 - Good
Quality of Management and Leadership - 4 - Good
Statement 1 5 - Very Good
Statement 4 4 - Good
6 Inspection and grading history
Date Type Gradings
14 Aug 2012 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 3 - Adequate
15 Dec 2011 Unannounced Care and support 4 - Good Environment Not Assessed Staffing 3 - Adequate Management and Leadership Not Assessed
23 Sep 2010 Announced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed
Burns Day Service, page 26 of 28 Inspection report continued
Management and Leadership 5 - Very Good
28 Oct 2009 Announced Care and support 5 - Very Good Environment Not Assessed Staffing 4 - Good Management and Leadership Not Assessed
19 Feb 2009 Announced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good
All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission.
Burns Day Service, page 27 of 28 Inspection report continued
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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