QUALITY AUDIT SUMMARY

QUALITY AUDIT SUMMARY

TABLE OF CONTENTS

Outcomes covered in this report

Outcome 1 - Respecting & involving people who use our service Outcome 2 - Consent to Care & Treatment

Outcome 3- Fees

Outcome 4 - Care & Welfare

Overview of Outcomes CQC Standards 1-3 Outcome 6 - Co-operation with other providers

Outcome 7 - Safeguarding people who use our Services Outcome 12 - Requirements relating to workers

Outcome 13 - Staffing

Overview of outcomes CQC standards 12-14 Outcome 15 - Statement of Purpose

Outcome 16 - Quality Audit

Outcome 17 - Concerns/Complaints

Overview of Outcomes CQC Standards 15-21

Larkstone Supported Living Family & Advocate Quality Assurance Survey Compliments, Comments & Suggestions

QUALITY AUDIT SUMMARY

Larkstone Supported Living Quality Audit

INTRODUCTION

At Larkstone Supported Living we are constantly auditing our service to ensure quality and compliance with the Care Quality Commission (CQC). As the regulator of health and adult social care in England, their role is to make sure that the care/support that people receive meets essential standards of quality and safety. At Larkstone Supported Living we encourage ongoing monitoring and reviewing of our policy and procedures in line with CQC. The Quality Audit summary report will be compiled and issued twice yearly, each outcome partly covered in each report and then a final overview report comprising of both report summaries will be issued. You can review our latest Quality Audit reports via our website www.larkstoneliving.co.uk or you can request a copy by contacting our head office:

Larkstone Supported Living Ltd Unit 4 Moxhams Court

12 Silver Street Barnstaple Devon EX32 8HR Tel: 01271 322819 Fax: 01271 322160 Email: [email protected]

This report can also be made available in easy read version with widgets if required. A detailed copy of the Care Quality Standards that Larkstone Supported Living adheres to are available at: www.cqc.org.uk All details of outcomes and action plans within this summary are collated from the procedures and documented evidence that Larkstone Supported Living have in place.

QUALITY AUDIT SUMMARY

SUMMARY OF OUTCOMES COVERED IN THIS REPORT

• Outcome 1 – Respecting and involving people who use our service • Outcome 2 – Consent to care and treatment

• Outcome 3 – Fees

• Outcome 4 – Care and Welfare

• Outcome 6 – Co-operation with other providers

• Outcome 7 – Safeguarding people who use our services from abuse • Outcome 12 – Requirements relating to Workers

• Outcome 13 – Staffing • Outcome 16 – Quality Audit

• Outcome 17 –Concerns/complaints • Outcome 15 – Statement of Purpose

OUTCOME 1: RESPECTING AND INVOLVING PEOPLE WHO USE OUR SERVICE

1. Service User’s internal 6 monthly reviews dairy dated with invites for next of kin and other agencies

2. All review outcomes/action plan kept in service user files as a working tool for staff to complete with service users

3. All service users given opportunity/invite to service users meetings – service users involved in reviewing Service User Guide – new service user ideas

implemented/amended and circulated

4. Service User assessments/reviews to be conducted by adult Learning Team – ongoing

• Action Plan: 3 – Review Service User Involvement in recording a DVD regarding Service User Guide in May 2013 – Ann Balchin (Director) and Senior Manager to organize

• Action Plan: 4 – Meeting with Senior Management to review recent assessments of Service User’s – Ann Balchin (Director) to arrange

QUALITY AUDIT SUMMARY

1. Following CQC report, new Mental Capacity Forms (MCA) implemented for Service User’s to be completed regarding decision making. Larkstone Supported Living now compliant

2. All correspondence to Service Users include a slip for Service User and Staff to sign to evidence that Service User understands content or requires an advocate/next of kin/other agencies involvement to support them.

3. Service User holiday forms reviewed and amended to include mental capacity 4. Service Users involved in new weekly activities in line with review of allocated

contracted hours – new visit list implemented to include the signing as evidence of staff visiting. These are signed by staff and the service user and then audited by Senior Manager.

Action Plan: 1- Monitor by all staff – to include involvement of advocates 4- Monitored by senior staff

OUTCOME 3: FEES

1. All Service User’s have notification of fees – standard met re: CQC report OUTCOME 4: CARE AND WELFARE

1. An assessment is carried out by Director/Senior Manager prior to any admissions to the service.

2. Health Action Planning Meetings were carried out with all Service User’s and Staff by Healthcare Professional and new Healthcare Action Plan Files implemented for Service User’s

3. All Service User’s care plan files in place and audited by a Senior Manger on a regular basis

QUALITY AUDIT SUMMARY

INVOLVEMENT & INFORMATION CQC STANDARDS 1-3

SERVICE USER LED SUPPORT PLAN IN PLACE

REVIEW OF CARE/SUPPORT MENTAL CAPACTITY ACT DOCUMENTATIO N IN PLACE FEEDBACK AND EVALUATION BY PEOPLE WHO USE THE SERVICE

Yes -Updated 23 Yes Due next _report

CQC STANDARDS 1-3 FEEDBACK AND EVALUATION BY FAMILY AND CARERS Yes – 32% responded – please refer to results on page 14 of report

OUTCOME 6: CO-OPERATION WITH OTHER PROVIDERS

1. Discussions/plans made with other provider /Care Manager re admission of new SU.

2. Discussions/Planning/visits made for with SU and the new provider-under Data Protection

OUTCOME 7: SAFEGUARDING PEOPLE WHO USE OUR SERVICES FROM ABUSE 1. Staff receive training on safeguarding SU’s from abuse-Senior Managers

trained/attended courses on the referral process. For safeguarding people who use our service.

2. Regular auditing of SU’s finances are carried out by a senior manager with audit reports.

QUALITY AUDIT SUMMARY

Action Plan: 3- Incident Reports- Medication errors have occurred all guidelines

followed. All existing staff to have a yearly refresher course / observation supervision- by December 2013

New auditing record for administration of SU’s medication to be implemented –all LSL Policy and Procedures re Medication to be reviewed.- April 2013

OUTCOME 12: REQUIREMENTS RELATING TO WORKERS

1. All new staff are selected by senior managers and the staff have the opportunity to visit both locations of the service prior to interview to ensure/measure suitability to the job role and also gives our service user’s and opportunity to meet with each applicant.

2. All new staff complete an application pack which includes application form, job specification form and equal opportunities form.

3. All new staff attend an interview with 2 x senior managers and 1 x service user in attendance. The service user has the opportunity to engage with the interviewee and ask their own questions. We have found service user involvement in this way has been extremely successful in recruitment of staff.

4. All new staff have an enhanced CRB and ISA check before commencing lone working with service user’s

5. 2 x references are required from the applicant before commencing work with our service user’s

6. All new staff complete a Common Induction Standards(CIS)questionnaire to measure competencies and plan induction and training needs

• Action Plan: Monitoring ongoing. OUTCOME 13: STAFFING

1. All new staff have a through induction which is planned following the new

QUALITY AUDIT SUMMARY

2. Casual workers employed to provide/maintain a flexible service for Service users to cover contracted staff Annual Leave, training and sickness.

• Action Plan: Monitoring ongoing.

OVERVIEW OF OUTCOMES CQC STANDARDS 12-14:

STAFFING CQC STANDARDS 12-14 NUMBERS EMPLOYED NEW STAFF THIS REPORT PERIOD REFERENCES OBTAINED X 2 CRB IN PLACE MADATORY TRAINING COMPETED INCLUDING CIS 42 6 100% 100% 100% STAFFING CQC STANDARDS 12-14 STAFF LEAVERS THIS REPORT PERIOD SUPERVISIONS & APPRSIALS SUSPENSIONS &DICIPLINARIES SU INVOLVEMENT IN RECRUITMENT 8 14 100% 100%

OUTCOME 15: STATEMENT OF PURPOSE

1. New amended/updated statement of purpose completed for Larkstone Supported Living Ltd – this has been circulated to all Service User’s/Staff/Next of Kin and CQC. A copy is also available on our website www.larkstoneliving.co.uk • Action Plan – Review Yearly

OUTCOME 16: QUALITY AUDIT

1. Larkstone Supported Living’s policy is to audit all CQC standards during January- July and July – December each year with summaries for each period and then a final overview at the end of each year compiling both summaries.

QUALITY AUDIT SUMMARY

2. All summaries will be available on the Larkstone Supported Living website or a copy can be requested from our Head office (please refer to further detail in Introduction of this report).

• Action Plan: To continue to monitor/review/action within timeframe. OUTCOME 17: CONCERNS/COMPLAINTS

1. All concerns raised have been processed/actioned within timeframe of 28 days as per procedure and 1 x service user informed of delay due to not able to contact to discuss.

2. Policy and procedures in place and included in reviewed Statement of Purpose 3. Next of Kin and Service User’s included in procedure how to complain/raise a

concern

4. 6 monthly Service User reviews give Service User and Next of Kin opportunity to share concerns

• Action Plan: To continue to monitor/review/action within timeframe.

OVERVIEW OF OUTCOMES CQC STANDARDS 15-21

QUALITY &MANAGEMENT CQC STANDARDS 15-21 STATEMENT OF PURPOSE NUMBER OF COMPLAINTS /CONCERNS POLICY & PROCEDURES IN PLACE CRB IN PLACE MADATORY TRAINING COMPETED INCLUDING CIS Updated and issued 5 concerns – Outcomes completed

Yes & currently

QUALITY AUDIT SUMMARY

Larkstone Supported Living Family & advocate quality assurance survey

Each year Larkstone supported living carries out a survey to find out how happy service user’s family and advocates are with us and the services provided. This is in line with CQC standards 1-3. This document illustrates the collected data from the surveys and is

broken down in 3 sections: • Our Staff

• Service user support • Our services

Our staff

The following questions were asked to our service user’s family and advocates:

• Are our staff polite and helpful? • Are they well presented?

• Do you feel confident in them?

• Do you feel they do their job in a professional way? • Are they thoughtful about your family member’s needs? • Do they respect your family member’s privacy and sensitive

situations?

• Do you feel they make the most the time they spend with your

family member?

• Do they communicate well with you and in an informative way? • Do you feel they have the necessary skills and training

QUALITY AUDIT SUMMARY

Our Staff - Results to questions

Overall, how happy are you with our staff?

Always 87% Usually 13% Sometimes 0% Never _0%

Our Staff

Our Staff

QUALITY AUDIT SUMMARY

Your Family member’s Support

The following questions were asked to our service user’s family and advocates:

• Are you happy with your family member’s support plan? • Do you feel their support plan is ‘person-centered’ enough?

80%

0% 20%

Support

QUALITY AUDIT SUMMARY

Your Family member’s support

• Do you feel that a wide enough choice of support and activities is available?

• Are you happy with the support and guidance our managers and staff give you?

• Are you happy with our financial and appointeeship services?

90% 10% 0% 0%

Support

QUALITY AUDIT SUMMARY

Our Services

• Are you happy with the quality of service we provide? • Do you feel we provide a professional service?

• If you contact us with a query, is your question answered? • Are your calls returned promptly?

• Do you we give you regular feedback?

• Do we hold six-monthly service reviews for your family member? • How happy are you with the way our office communicates with you? • If you have any concerns, do you feel these are dealt with quickly and

properly?

• Do you know how to make a complaint?

80% 16% 2% 2%

Our Services

QUALITY AUDIT SUMMARY

Overall, how happy are you with our the quality of our services?

Would you recommend our services?

0 10 20 30 40 50 60 70 80 90 100

Very Happy Happy Unhappy Very Unhappy

Our Services

Our Services

QUALITY AUDIT SUMMARY

Compliments, Comments & Suggestions

As part of the survey Larkstone also asked Next of Kin and advocates the following questions:

• Please tell us if there is anything you feel we do well.

• Please tell us if there is anything you feel we could do better. • Is there anything else you would like to tell us?

• Please tell us if there is anything you feel we do well.

We received the following comments, compliments and suggestions:

“The main office telephone in Barnstaple is always answered very quickly, and someone is always available to help in anyway”.

“The Ilfracombe team have taken great care to consider C’s preferences, likes and dislikes, and I know that they are always ready to help in anyway if anything unexpected occurs”

“Thank you so much for everything you do to help C in every way you can and help the wider family too, with such things as travel planning, financial planning etc. We are all very grateful.”

“Over the latter months the activities seemed to have improved, noticing B is doing a lot more”

QUALITY AUDIT SUMMARY

Company Information

Larkstone Supported Living Limited Unit 4 Moxhams Court

12 Silver Strett Barnstaple Devon EX32 8HR Tel 01271 322819 Fax 01271 322160 Email: [email protected] www.larkstoneliving.co.uk