davidshill farm school care accommodation...

Davidshill FarmSchool Care Accommodation ServiceDavidshill FarmDalryKA24 4JD

Type of inspection: Unannounced

Inspection completed on: 4 December 2014

ContentsPage No

Summary 31 About the service we inspected 52 How we inspected this service 73 The inspection 104 Other information 235 Summary of grades 246 Inspection and grading history 24

Service provided by:Spark of Genius (Training) Ltd

Service provider number:SP2006008009

Care service number:CS2007157693

If you wish to contact the Care Inspectorate about this inspection report, please callus on 0345 600 9527 or email us at [email protected]

Inspection report continued

Davidshill Farm, page 2 of 27

SummaryThis report and grades represent our assessment of the quality of the areas ofperformance which were examined during this inspection.

Grades for this care service may change after this inspection following otherregulatory activity. For example, if we have to take enforcement action to make theservice improve, or if we investigate and agree with a complaint someone makesabout the service.

We gave the service these grades

Quality of Care and Support 5 Very Good

Quality of Environment 6 Excellent

Quality of Staffing 5 Very Good

Quality of Management and Leadership 6 Excellent

What the service does wellYoung people at Davidshill enjoy warm and supportive relationships with staff. Theservice has now fully established high quality, person centred care plans and riskassessments. These make excellent use of the "Getting it Right for Every Child"(GIRFEC) framework.

Management and staff have made excellent use of family insight, training and linkswith other professionals to ensure they communicate effectively with all youngpeople, some of whom have significant communication needs. These improvementshave translated into improved outcomes for young people.

The service is making excellent use of their well established quality assurancesystems to ensure that the environment is safe and each young person's care plan iscarried out in full.

What the service could do betterThe service should continue to build on the good work done to better understand thediverse challenges posed by the group of young people staying at Davidshill. Furtherintegration of the services provided by the Clinical Psychologist will help developsupport arrangements for young people.



What the service has done since the last inspectionThe service has consolidated the use of the new care planning materials. These hadrecently been audited against rigorous criteria set out in the providers qualityassurance framework. We reviewed all of the documentation and agreed that thispresented an excellent picture of the young person, their targets and the positiveoutcomes achieved. Young people played a significant part in their care plans.

The service had continued to improve the environment with the new Barn areaproviding an excellent space for young people.

The service had made significant improvements to how the adjacent Equestriancentre played a full yet discreet part in the life of the house.

ConclusionDavidshill is clearly benefitting from having an experienced manager. We found veryhigh standards of care planning, risk assessments, quality assurance andenvironment.

There is a group of young people who compliment each other creating a settledenvironment where every achievement is recognised and celebrated. As notedthroughout the report these achievements have been significant in improving thequality of life of young people.



1 About the service we inspectedThe Care Inspectorate regulates care services in Scotland. Information about all careservices is available on our website at www.careinspectorate.com

This service was previously registered with the Care Commission and transferred itsregistration to the Care Inspectorate on 1 April 2011.

Requirements and Recommendations

If we are concerned about some aspect of a service, or think it could do more toimprove, we may make a recommendation or requirement.

- A recommendation is a statement that sets out actions the care service providershould take to improve or develop the quality of the service but where failure to do sowill not directly result in enforcement. Recommendations are based on the NationalCare Standards, relevant codes of practice and recognised good practice.

- A requirement is a statement which sets out what is required of a care service tocomply with the Public Services Reforms (Scotland) Act 2010 and Regulations orOrders made under the Act or a condition of registration. Where there are breaches ofthe Regulations, Orders or conditions, a requirement must be made. Requirements arelegally enforceable at the discretion of the Care Inspectorate.

Davidshill Farm holds registration for School Care Accommodation. The service mayprovide care for a maximum of 5 young people aged between 9 years and 17 years atDavidshill Farm.

Spark of Genius (Training) Ltd. (Spark of Genius) provides this service and operates a24-hour service 52 weeks of the year. Davidshill Farm is located near Dalry in NorthAyrshire.

The service provides the residential living accommodation for the young people andtheir educational needs are met through attendance at learning centres also providedby Spark of Genius, or at other educational provision, whichever is identified in careplans.

Davidshill Farm has a full time manager to run the day-to-day service. The manageris supported by a senior practitioner and the head of children's services.

The following is part of a statement by the Managing Director of Spark of Genius onthe Spark of Genius website:



'Spark of Genius wants to make life changing experiences available for all our childrenand young people, through the care we provide, the education and communitysupport we offer and the continuing relationship we have with our young people,their families and carers'.

Based on the findings of this inspection this service has been awarded the followinggrades:

Quality of Care and Support - Grade 5 - Very GoodQuality of Environment - Grade 6 - ExcellentQuality of Staffing - Grade 5 - Very GoodQuality of Management and Leadership - Grade 6 - Excellent

This report and grades represent our assessment of the quality of the areas ofperformance which were examined during this inspection.

Grades for this care service may change following other regulatory activity. You canfind the most up-to-date grades for this service by visiting our websitewww.careinspectorate.com or by calling us on 0345 600 9527 or visiting one of ouroffices.



2 How we inspected this service

The level of inspection we carried outIn this service we carried out a low intensity inspection. We carry out theseinspections when we are satisfied that services are working hard to provideconsistently high standards of care.

What we did during the inspectionWe wrote this report following an unannounced visit to the service on 10 November2014 and a follow-up visit on 4 December 2014.

In this inspection we gathered evidence from various sources, including the relevantsections of policies, procedures, records and other documents including:

- Certificates of Registration and Insurance- Questionnaires young people, parents, staff and stakeholders- Minutes of meetings young people and staff- Complaints records- Absconding records- Care Plans- Child Protection records- Individual risk assessments and audits- Medication records- Safehold records- Safety Checks- Kitchen safety and cleaning records- Premises and risk assessments- Staff supervision and appraisal programme- Staff rotas- Staff training records- Development Plan.

We also conducted a tour of the premises and observed staff working with youngpeople.



We also spoke with:

- Young people- The Manager and Care staff- Service Manager- Social Worker- Family Members.

Grading the service against quality themes and statementsWe 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'. Undereach quality theme are 'quality statements' which describe what a service should bedoing well for that theme. We grade how the service performs against the qualitythemes 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 ourinspections. These are extra checks we make on top of all the normal ones we makeduring inspection. We do this to gather information about the quality of these aspectsof care on a national basis. Where we have examined an inspection focus area we willclearly identify it under the relevant quality statement.

Fire safety issuesWe do not regulate fire safety. Local fire and rescue services are responsible forchecking services. However, where significant fire safety issues become apparent, wewill alert the relevant fire and rescue services so they may consider what action totake. You can find out more about care services' responsibilities for fire safety atwww.firelawscotland.org



The annual returnEvery year all care services must complete an 'annual return' form to make sure theinformation we hold is up to date. We also use annual returns to decide how we willinspect the service.Annual Return Received: Yes - Electronic

Comments on Self AssessmentEvery year all care services must complete a 'self assessment' form telling us howtheir service is performing. We check to make sure this assessment is accurate.The self assessment had been updated to reflect improvements within the service.Clearer links between improvements, interventions and outcomes would improve theself assessment.

Taking the views of people using the care service into accountWe spoke with 3 young people. One was able to talk in detail about specificoutcomes for him. This was extremely helpful in building on evidence provided forconsideration at the inspection. He confirmed how he had come up with an idea toimprove how he was feeling about living in the house. As explained in 1.1 this wasfully actioned and led to a positive outcome for the young person.

The 2 other young people told us they were very happy at Davidshill.

Taking carers' views into accountThe service receives regular feedback from carers. Most feedback is very positive.



3 The inspectionWe looked at how the service performs against the following quality themes andstatements. Here are the details of what we found.

Quality Theme 1: Quality of Care and SupportGrade awarded for this theme: 5 - Very Good

Statement 1We ensure that service users and carers participate in assessing and improving thequality of the care and support provided by the service.

Service strengthsThe grade awarded for this quality statement was 6 - Excellent.

We came to this conclusion following a thorough review of all aspects of the service'sparticipation strategy. Our findings were supported by well presented evidence whichincluded the views of young people and their families and the views of otherprofessionals such as social workers.

The service had built on the high standards of participation evident in previousinspections. To achieve this, key teams had undertaken training to ensure that theyand others could communicate effectively with young people with significantcommunication needs. For example, one young person with limited speech usedMakaton and staff had attended classes to ensure they could communicate effectivelywith him. This was well evidenced in the young person's care plan which highlightedagreed targets around self confidence, living with others and improvedcommunication.

The service had worked closely with their own education centre to improveconsistency and had worked with other schools on the use of Story Boards, iPad, PECSand other communication tools. These efforts were reflected in improved levels ofparticipation. For example, young people who could not participate fully in meetingswere now playing a more active part and young people were now making informedchoices about activities, clubs, friends and family. These outcomes are reflected instatement 1.3.



We concluded that staff had used their additional skills in communication to helpthem understand the needs of young people, communicate more effectively withthem and ensure their wishes were translated into outcomes. Keytime which tookplace on a 1:1 basis had increased and was very well recorded using pictorial aidswhere needed to reflect the views and mood of young people. A significant focus ofkeytime had been to ensure that each young person's room was individualised andreflected their likes and personalities. We found all rooms to be individualised andappropriate to the age and stage of young people. For example, lighting, furnishings,window coverings and beds all reflected the individual choice of young people. Inaddition, toys and equipment were consistent with the interests and hobbies of eachyoung person. For example, collectables, construction toys and musical preferenceswere well represented. Where requested rooms were decorated in the colour ortheme or choice; for example, Toy Story.

We saw excellent evidence that took us on a journey from an idea raised by a youngperson who felt they needed time out of the house to reduce his anxiety and allowhim to better fit in with the group. The young person was fully involved in planningand gathering evidence including receipts, invoices, pictures and an itinerary. Theyoung person confirmed in discussion that they were less anxious in and around thegroup and that they felt the manager (who accompanied the young person toLondon) had gone above and beyond what they expected in order to offer them anexcellent experience with a very positive outcome.

All aspects of the participation strategy had been subject to careful review by theexternal quality assurance manager. The inclusive nature of the work undertaken bystaff and the high levels of participation achieved with a very diverse group of youngpeople, added to the positive outcomes illustrated above, make this sector leading forwork with young people in School Care Accommodation services.

Areas for improvementThe service should continue to equip staff to improve their communication withyoung people. This is important if staff are going to develop their roles as advocatesfor young people.

Grade awarded for this statement: 6 - Excellent

Number of requirements: 0

Number of recommendations: 0



Statement 3We ensure that service users' health and wellbeing needs are met.

Service strengthsThe grade awarded for this quality statement was 5 - Very Good.

The service continued to maintain well established relationships with primary healthcare resources such as GP's and dentists and Looked After and Accommodated (LAAC)Nurses. Where more specialist support was required young people were offeredsupport from Community Adolescent Mental Health Services (CALMS).

The service had been piloting the providers new care planning and risk assessment(see 2.2) documentation.

This was now well established within the service and had been subject to a series ofimprovements before it was rolled out to other Spark of Genius services.

We found the new care plans to be more user-friendly, person centred and madebetter use of the "Getting it Right for Every Child" (GIRFEC) framework. Targets wereSMART and set within the GIRFEC framework and reflected decisions made at multi-disciplinary meetings such as Looked After and Accommodated (LAAC) Reviews. Therewas clear evidence that young people aided where appropriate by communicationsupports had been involved in creating a clearer picture of themselves and had beeninvolved in target setting against the SHANARRI well-being outcomes.

Young people were generally doing well at Davidshill Farm. Each had made progressin a number of areas. Some of the changes, for example continence management,had made a significant improvement to the quality of life of a young person. Otherplanned interventions had led to improved sleeping patterns that had allowed ayoung person to spend overnights at home for the first time in years.

Young people were supported by a member of staff whose main responsibility was tosupport them in their education setting. This had improved communication andhelped staff in both settings to understand the targets set with young people and hadhelped ensure greater consistency in meeting their complex needs.

Young people now had the support of a Clinical Psychologist and their guidance andsupport was well recorded within the care plans. This was particularly helpful whenworking to achieve specific goals in relation to behaviour, social skills, sleepingpatterns and self-esteem. In addition the Psychologist had developed a betternarrative with CAMHS services resulting in referrals that had previously been turneddown had now been accepted following their intervention.



Young people had access to very good garden space and the adjacent stables. Thisallowed young people the opportunity to enjoy free play and to play and work withdifferent animals. Attendance at a variety of activities happened on a regular basis.Young people told us they attended youth clubs, football, swimming, rock climbing,horse riding and drama. These activities had contributed to the improvements notedin young people. For example, drama had played a key part in improving the self-esteem of young people.

Areas for improvementThe service should build on the significant improvements in their overall approach tothe support of young people.

We noted that some care plans were better developed than others. For example, thetargets for achievement in one file did not reflect the effective work done alongsideeducation staff. All plans should better reflect the joint targets set with educationand the house should be developed into an educationally rich environment which cansupport this. (See recommendation 1 for this quality statement).

Grade awarded for this statement: 5 - Very Good



Recommendations

1. The service should develop their approach to supporting young people to achieveeducation and other targets. NCS, School Care Accommodation, Standard 14:Supporting Your Education.



Quality Theme 2: Quality of EnvironmentGrade awarded for this theme: 6 - Excellent

Statement 1

We ensure that service users and carers participate in assessing and improving thequality of the environment within the service.


The influence of young people was very evident throughout the house. Rooms werevery different and reflected the needs, interests and wishes of young people. Thiswas also evident in shared areas such as the Barn where young people haspersonalised their bit of it. For example, one young person advertised and reflectedthe success of his enterprise initiative.

Please see statement 1.1 for more details.

Areas for improvementSee statement 1.1.






Statement 2We make sure that the environment is safe and service users are protected.

Service strengthsThe grade awarded for this quality statement at the last inspection in March 2014 was6 - Excellent.

Following a review of that evidence and close consideration of the ongoingimprovements the grade awarded will remain 6 - Excellent.

Young people, family members and others spoke very highly about the ongoingimprovements to the environment. These included continued improvements tooutside space, the further development of the Barn, improved integration of theEquestrian Centre and the creation of improved dining room a nd sitting room spaces.

These changes had been underpinned by improvements to the generic, environmentaland individual risk assessment. These had an improved format which was clear andeasy to follow. For example, there were comprehensive risk assessments about theinteraction with animals, outings and specific activities involving young people. Wenoted the clear links between risk assessments and planned interventions to supportyoung people in crisis.

All staff had undertaken mandatory training in areas such as TCI, child protection andinfection control. These were essential giving the diverse needs of the group of youngpeople. As mentioned in statement 1.1 key teams and others had undertaken clientspecific training to ensure the safe and person centred support of each youngperson. This had resulted in a wide range of positive outcomes as highlighted instatement 1.3.

We noted that additional staff were often deployed in the evenings to allow for safecare and to facilitate the wide range of activities undertaken by young people.

The improved integration of the equestrian centre had led to increased use by youngpeople, but more importantly it was now a vocational centre offering SVQ's to youngpeople. This was again underpinned by improved risk assessment and clearer links topositive outcomes for young people. For example, there was clear evidence of thepreparation and safety measure put in place when young people from Davidshillattended a number of community events with the horses.



Areas for improvementThe service should continue to develop their approach to working with other agenciesaround the issues of risk management.






Quality Theme 3: Quality of StaffingGrade awarded for this theme: 5 - Very Good

Statement 1We ensure that service users and carers participate in assessing and improving thequality of staffing in the service.


Young people at all ages and stages had the opportunity to play an important part inthe staff selection process. We also noted that key teams within Davidshill had beencarefully considered and matched to the needs of young people.


Areas for improvementSee statement 1.1.






Statement 3We have a professional, trained and motivated workforce which operates to NationalCare Standards, legislation and best practice.

Service strengthsThe grade for this quality statement was 5 - Very Good.

We concluded that the service had maintained the very good standards achievedagainst this quality statement at the inspection of March 2014.

We found that all staff had registered with the Scottish Social Services Council. Inaddition, all staff had completed mandatory training to ensure safe care at all times inDavidshill.

The service had in place relevant policies and procedures to ensure that it had aprofessional, trained and motivated workforce which operated to National CareStandards, legislation and best practice. Staff we spoke with as part of this inspectiondemonstrated a clear knowledge of child protection and the legislative frameworkwhich allowed young people to be cared for away from home. There was a policy andprocedure in relation to staff recruitment to ensure that all staff were recruited andinducted in a safe and robust manner and service users were protected.

All staff had completed a period of induction and had completed a full programme ofmandatory training including, child protection TCI and health and safety. As part ofthe induction, staff were required to familiarise themselves with the service's policiesand procedures. This ensured that staff possessed the required knowledge skills andexpertise to care for the children and young people who used the service.

Staff training records provided a written record of when individual staff hadcompleted training and when it was required to be updated. We found that staff wereencouraged to access training relevant to young people's needs. This is welldocumented in statement 1.1 where it is noted staff had accessed training to improvetheir communication with young people. This had led to greater inclusion and hadcontributed to positive outcomes for young people.

There was a system in place for all staff to receive supervision and annual appraisals.The staff spoken with as part of this inspection confirmed that they received regularsupervision. All staff that we spoke with during the inspection confirmed that they feltthat managers with whom they had regular contact had very much an open doorpolicy and that they did not have to wait for formal supervision to approach them foradvice or guidance.

Young people told us that although staff could be frustrating they were "doing a goodjob" and that all young people were "well cared for".



There continued to be regular staff meetings. Staff valued these and stated that theycontributed to the strong team values in place at Davidshill. Staff told us there wasvery good communication and that staff supported each other with maintaining aconsistent approach to the care of young people even if this was difficult at times. Forexample, if aspects of a young persons diet required to be followed or specific careand support needs had to be met all staff would ensure these interventions tookplace. Staff felt this was a big improvement to their previous experience in this andother care settings.

Areas for improvementThe staff team at Davidshill were offering high quality support to youngpeople. Despite this we felt their was still room for further staff development. Theprovider should explore this with staff as part of their team development day.

Staff should be reminded to ensure they have a clear path to achieving their SSSCregistration requirements.

Grade awarded for this statement: 5 - Very Good





Quality Theme 4: Quality of Management and LeadershipGrade awarded for this theme: 6 - Excellent

Statement 1We ensure that service users and carers participate in assessing and improving thequality of the management and leadership of the service.


Young people continued to have regular access to managers at all levels within theorganisation. This included informal and formal contact through the Spark Parliamentwhich had implemented changes to allowances and other key issues important toyoung people.


Areas for improvementPlease see statement 1.1 for more details.






Statement 4We use quality assurance systems and processes which involve service users, carers,staff and stakeholders to assess the quality of service we provide


From discussion with the manager and from our observations during this inspectionwe found that the service continued to meet the very good standard awarded for thisstatement at the previous inspection as outlined below:

We found that young people now live in a house that is effectively managed in theirbest interests. The manager and staff had a clear and strong commitment toimprovement. This was evidenced in the improvements made to the house, therecording systems and more particularly in the improvements made by young people.

The provider organisation had a variety of service audit systems in place at differentcorporate levels. These included a comprehensive Quality Improvement report, PeerManager audits and daily audits carried out by staff. The robust Quality Improvementprogramme has allowed staff and young people to work together to improve thequality of the service. Outcomes of discussions at staff meetings and young people'smeetings had been used to inform service planning.

We sampled internal and external auditing systems that assist the performance of theservice. By this we mean how they check the support for each young person, healthand safety issues and ensuring action plans are devised to make improvements.Management and staff demonstrated through discussions and within records thatregular checks were carried out across different aspects of the care being provided atDavidshill Farm.

We found that recent audits of the new care planning materials were themselvesperson centred and demanded the highest standards. The service had achievedextremely well and this was consistent with the findings of the inspection.

Senior managers and directors visited the service regularly and shared informationand ideas with young people and staff. Management were fully involved in all aspectsof the service and were described by young people, staff, stakeholders and parents asapproachable, supportive and professional.

All service users, carers, staff and stakeholders we spoke with as part of thisinspection confirmed that they were very much involved in the ongoing assessment ofthe quality of care provided by Davidshill Farm and all felt that their opinions werevalued.



Areas for improvementThe very highest standards achieved at recent quality assurance checks should beachievable against all aspects of the service.






4 Other information

ComplaintsNo complaints have been upheld, or partially upheld, since the last inspection.

EnforcementsWe have taken no enforcement action against this care service since the lastinspection.

Additional Information

Action PlanFailure to submit an appropriate action plan within the required timescale, includingany agreed extension, where requirements and recommendations have been made,will result in the Care Inspectorate re-grading a Quality Statement within the Qualityof Management and Leadership Theme (or for childminders, Quality of StaffingTheme) as unsatisfactory (1). This will result in the Quality Theme being re-graded asunsatisfactory (1).



5 Summary of grades

Quality of Care and Support - 5 - Very Good

Statement 1 6 - Excellent

Statement 3 5 - Very Good

Quality of Environment - 6 - Excellent



Quality of Staffing - 5 - Very Good


Statement 3 5 - Very Good

Quality of Management and Leadership - 6 - Excellent



6 Inspection and grading history

Date Type Gradings

19 Dec 2013 Unannounced Care and support 5 - Very GoodEnvironment 5 - Very GoodStaffing 5 - Very GoodManagement and Leadership 5 - Very Good

28 May 2013 Unannounced Care and support 5 - Very GoodEnvironment 5 - Very GoodStaffing 5 - Very GoodManagement and Leadership 5 - Very Good

23 Oct 2012 Unannounced Care and support 4 - GoodEnvironment 5 - Very GoodStaffing 4 - GoodManagement and Leadership 4 - Good



22 May 2012 Unannounced Care and support 3 - AdequateEnvironment 4 - GoodStaffing Not AssessedManagement and Leadership Not Assessed

12 Dec 2011 Unannounced Care and support 2 - WeakEnvironment 3 - AdequateStaffing Not AssessedManagement and Leadership Not Assessed

19 May 2011 Unannounced Care and support 3 - AdequateEnvironment 3 - AdequateStaffing Not AssessedManagement and Leadership Not Assessed

9 Dec 2010 Unannounced Care and support 5 - Very GoodEnvironment Not AssessedStaffing Not AssessedManagement and Leadership 5 - Very Good

29 Jul 2010 Announced Care and support 5 - Very GoodEnvironment Not AssessedStaffing Not AssessedManagement and Leadership 5 - Very Good

4 Feb 2010 Unannounced Care and support 5 - Very GoodEnvironment Not AssessedStaffing 5 - Very GoodManagement and Leadership Not Assessed

2 Oct 2009 Re-grade Care and support Not AssessedEnvironment Not AssessedStaffing 4 - GoodManagement and Leadership Not Assessed

17 Aug 2009 Re-grade Care and support Not AssessedEnvironment Not AssessedStaffing 2 - WeakManagement and Leadership Not Assessed



18 Feb 2009 Unannounced Care and support 4 - GoodEnvironment 4 - GoodStaffing 4 - GoodManagement and Leadership 4 - Good

26 Aug 2008 Announced Care and support 4 - GoodEnvironment 4 - GoodStaffing 4 - GoodManagement and Leadership 4 - Good

All inspections and grades before 1 April 2011 are those reported by the formerregulator of care services, the Care Commission.



To find out more about our inspections and inspection reportsRead our leaflet 'How we inspect'. You can download it from our website or ask us tosend you a copy by telephoning us on 0345 600 9527.

This inspection report is published by the Care Inspectorate. You can get more copiesof this report and others by downloading it from our website:www.careinspectorate.com or by telephoning 0345 600 9527.

Translations and alternative formatsThis inspection report is available in other languages and formats on request.

Telephone: 0345 600 9527Email: [email protected]: www.careinspectorate.com



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