Inspection on 08/03/05 for Dilston College Of Further Education

Care Homes For Adults (18 ­ 65)Dilston College Of Further EducationCorbridge Hexham Northumberland NE45 5RJUnannounced Inspection8th March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Dilston College Of Further Education Address Corbridge, Hexham, Northumberland, NE45 5RJ Email address marilyn.hunter@dilstoncollege.com Name of registered provider(s)/company (if applicable) Royal Mencap Society Name of registered manager (if applicable) Mr J A Jameson Type of registration Care Home No. of places registered (if applicable) 52 Tel No: 01434-632692 Fax No: 01434-633721Category(ies) of registration, with (number of places) Learning disability (52) Registration number B030000152 Date first registered 12th June 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply? Date of last inspectionDate of latest registration certificate 21st January 2004 YES NO 7/7/04 If Yes refer to Part CDilston College Of Further EducationPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 38th March 2005 10:00 am Bill MiddlemistID Code074131Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMarilyn HunterDilston College Of Further EducationPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementDilston College Of Further EducationPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Dilston College Of Further Education. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Dilston College Of Further EducationPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Dilston College of Further Education is part of the Mencap organisation; it provides education and training combined with care and support for up to 52 students who have a learning disability. The college has large grounds with lots of open space; it is close to Northumbrian towns of Corbridge and Hexham, where there are good local shops and things to do in the community, such as pubs, cinemas, gyms and job experience opportunities. The nearest city is Newcastle and can be easily reached by train or bus. The college is divided in to several units in the main building and there are others dotted around the site. There is a lively and positive atmosphere at Dilston College. The college is referred to as a care home for registration purposes.Dilston College Of Further EducationPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection focused on key standards which were not assessed at the last inspection, along with other standards judged to be necessary. This is in line with the current CSCI policy of proportionality. As a result there are a number of standards in the report which have not been assessed.Choice of Home (Standards 1-5) 2 of these 5 standards were assessed and commended If you are a student, parent or carer who wants to consider Dilston College then they will send you all the information you need to help you start making your mind up. The college will ask for more information about you ­ this will be called an assessment. You might then be invited to the college for a stay over a few nights where the staff will try to learn more about you and see if you are going to get something good out of living, studying and working at the college for a few years. If the college agrees to you going there, they will arrange with you what are going to learn and how you will be helped. Individual Needs and Choices (Standards 6-10) 4 of these 5 standards were assessed and commended The college will work with you to make up plans about what and how you are going to learn. Some things you will learn may involve risks and the college will help you work through this. The plans will be discussed with you to make sure that the kind of support you need is right for you, and will be changed if you need different ­ either more or less, support. Lifestyle (Standards 11-17) All of these 7 standards were met, 6 are commended Dilston College is excellent at helping students develop all aspects of their lives; they assist students to learn about things that are important to young people. Learning about new things is done both within the college and out in the community; qualified and experienced staff are there to support and encourage students. There is always something to do at the college. Personal and Healthcare Support (Standards 18-21) 2 of these 4 standards were assessed and commended All students are encouraged to be independent regarding things like going to the doctors or dentists; staff will offer help and support when necessary. If you take any tablets or medicines the college will ensure that you will get any help that you might need. If you are not feeling well staff will ensure that are seen as soon as possible. Concerns, Complaints and Protection (Standards 22-23) Each of these 2 standards were met, 1 is commended The staff will help you to make a complaint if you are not happy with any part of your life at the college; the college is good at listening to students and parents concerns, and is quick to make changes to improve things. Environment (Standards 24-30) 2 of these 7 standards were assessed and met The college has large grounds with lots of open space; it is close to Northumbrian towns of Corbridge and Hexham, where there are good local shops and things to do in the community, such as pubs, cinemas, gyms and job experience opportunities. The nearest cityDilston College Of Further EducationPage 6 is Newcastle and can be easily reached by train or bus. The college is divided in to several units in the main building and there are others dotted around the site. There is a lively and positive atmosphere at Dilston College. Staffing (Standards 31-36) 3 of these 6 standards were assessed and met, 2 are commended All staff appear to enjoy their jobs at Dilston College and get on well with students; there are enough staff around to help students when they need it. The college takes care when taking on new members of staff and does checks on them to see if they have the right qualifications and attitudes. The college then gives each member of staff a lot of training so that they can be even better at their jobs. Conduct and Management of the home (Standards 37-43) 5 of these 7 standards were met, 3 are commended Dilston College is managed by a number of people who are really good at their jobs; they try to make sure that each student is well looked after and get all the opportunities they need, as well as making sure that the college is as safe as possible for everyone. The management team take their jobs seriously and are always looking at ways to make a good college even better. Again, this was an outstanding inspection at Dilston. The inspector would like to thank students, staff and management for their hospitality and contributions to this inspection. There are no requirements or recommendations arising from this inspection.Dilston College Of Further EducationPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Dilston College Of Further EducationPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard *Dilston College Of Further EducationPage 9 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Educational sessions `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO YES 19 0 0 NA NA YES YES X X 8/3/05 10/00 5Dilston College Of Further EducationPage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Dilston College Of Further EducationPage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to `test drive the home. Each service user has an individual written contract or statement of terms and conditions with the home.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are Key findings/EvidenceStandard met?0The colleges statement of purpose was assessed and commended at the previous inspection.Dilston College Of Further EducationPage 12 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 4 Key findings/Evidence Standard met? The process for taking in new students at Dilston College has been commended at previous inspections; this continues to be the case at this inspection. The college provided evidence that students are only admitted following a comprehensive assessment carried out usually by a range of professionals. The college develops the service user plan based on core assessments, and clearly states any potential restrictions on choices, freedom, services or facilities.Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 4 Key findings/Evidence Standard met? The college continues to demonstrate its significant capacity to meet students needs. Any student attending Dilston College will know that their individual needs will be met, irrespective of age or disability. Throughout this inspection, staff again both individually and collectively demonstrated that they have skills and values essential for working with people who have learning disabilities; staff are further supported by an excellent programme of induction and on going training. The staff are supported by a professional, competent and highly motivated management team. The inspector observed staff using effective communication with a range of students in a number of different situations, and easily demonstrated the positive outcomes students were achieving.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This standard was assessed and commended at the previous inspection.Dilston College Of Further EducationPage 13 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This standard was assessed and commended at the previous inspection.Dilston College Of Further EducationPage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 4 Key findings/Evidence Standard met? The college calls service user plans Individual Learning Programmes; these are plans that set out what students are to learn and how they will learn them, they are reviewed regularly and revised as a result of reviews. The college works hard to assist students plan for the future and encourages the involvement of other professionals in the process; if there is some indicator that planning for the future is not ideal then it is not for the colleges want of trying ­ this is being raised by the Commission For social Care Inspection elsewhere.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 4 Key findings/Evidence Standard met? Dilston College continues to promote students rights to make decisions and informed choices. Students rights are positively regarded at the college, and all systems are geared towards encouraging students not only to make choices, but to make informed choices in as many aspects of the their lives as possible. Students who need assistance with understanding and using money are supported by learning programmes to enable greater independence. Any limitations for students are carefully considered, recorded and if necessary, risk assessed.Dilston College Of Further EducationPage 15 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 4 Key findings/Evidence Standard met? Students are encouraged to be involved in the running of the college in a number of different ways; they are involved in inspecting the various buildings on the site, there are students representatives at all levels within the organisation.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 4 Key findings/Evidence Standard met? There is continuing evidence that students are encouraged to take risks as part of their learning and development, and that this is done within the framework of good risk assessment and risk management systems. Dilston College acknowledges that taking risks is essential to students development; risk assessment is taken very seriously and students can develop their independence knowing that the colleges systems for risk assessment and risk management will support them.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was assessed and met at the previous inspection.Dilston College Of Further EducationPage 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate, personal, family and sexual relationships. Service users rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 4 Key findings/Evidence Standard met? The evidence for this standard continues to be commendable. Dilston College is all about giving students opportunities for personal development. The inspector has known some students for several years, and clear and positive outcomes have been achieved. Several students demonstrated and talked about what they have learned and achieved. There is a good mixture of leisure and learning. Each student has an annual summary based on a baseline assessment of developmental needs; these clearly chart the outcomes that have been achieved.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 4 Key findings/Evidence Standard met? Many of the students identify what they want to achieve as a result of being at college; many want to have a job and to live independently ­ all activities at the college support these aims. The Essential Skills Award details course objectives and projected outcomes for students, this leads to an Individual Learning Plan and priorities for each term. Each student has an individual schedule that supports their aims, and may include, among many things, daily living skills and personal care, literacy and numeracy, small animal care, catering skills, horse riding, Womens and Mens groups, Creative Dance Skills and developing communication. Many activities at the college combine learning and leisure; students can gain certificates as evidence of developing skills and abilities.Dilston College Of Further EducationPage 17 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 4 Key findings/Evidence Standard met? Students at Dilston College continue to have many opportunities to become part of the local community; one of the key aims for students is to actively be part of the community and this is evidenced through the Community and Leisure part of students individual plans. Several students informed the inspector of their activities both within and outside of the college, and how much they enjoyed going to the local towns and nearby cities. Students staff The Castle Café that is part of the Dilston Castle and Chapel heritage site; organic produce that students grow on the estate is sold by students at the local farmers market. Students make good use of local facilities in Corbridge and Hexham, as well as in Newcastle and Gateshead.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met?4All students are continue to have access to an excellent range of leisure activities that are suitable to their needs and interests; organised activities take place both inside and outside of the college, and there is a suitable choice of more domestic entertainment through DVDs, music and television.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 4 Key findings/Evidence Standard met? Systems to support students and their families and friends continue to be commendable. All students are encouraged to develop and maintain a range of relationships. Students can receive visitors in private, and if there are any associated risks then the college will assess and record them. Students have ample opportunities to meet people who do not have disabilities through their use of the community. Students who develop intimate relationships can by supported by qualified counsellors should the need arise.Dilston College Of Further EducationPage 18 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 4 Key findings/Evidence Standard met? There is very good evidence that life at Dilston College positively encourages independence, choice and freedom of movement; restrictions as to freedom of movement will only be imposed to promote student safety and will be suitably explained and recorded. All daily routines are documented and actively promote students to take responsibility and recognise their rights. Students right to privacy is encouraged and respected. The inspector noted unopened mail for students while touring the college, and that staff were interacting with students throughout the inspection. Students have unrestricted access to all parts of the college apart from those areas where Health and Safety prevents them.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Most students have their main meal of the day in the dining hall of the main building; this is prepared and served by students under the supervision of staff. Other meals are prepared in the various units around the site, again with training and supervision where needed. Care is taken to ensure that meals are varied and that students preferences are taken into consideration without rigidly sticking to organised menus. The college can cater for alternative diets according to individual cultural needs.Dilston College Of Further EducationPage 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the homes policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard was assessed and commended at the previous inspection.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence Standard met? X0 4As with all other aspects of life at Dilston College, students are encouraged to be as independent as possible in meeting healthcare needs. All students are registered with a local GP practice, and staff actively monitor students for any potential complications.Dilston College Of Further EducationPage 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? This standard was assessed and met at the previous inspection.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 4 Key findings/Evidence Standard met? Students will know that any illness they develop will addressed effectively and with respect. The college has recently provided excellent evidence that the illness of students is addressed in a thorough, sensitive and professional manner. A Consultant from Newcastle General Hospital commended the college for its good practice and procedures.Dilston College Of Further EducationPage 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence 3 X X 0 1 0 100 Standard met? 4The college has an effective complaints procedure that is combined with an attitude of learning from any complaints findings. Good evidence has been provided that complaints are treated in a professional and open manner, and that the college are efficient in regulating its own activities. Three complaints have been logged and resolved satisfactorily since the last inspection, and one was ongoing at the time if this inspection.Dilston College Of Further EducationPage 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence YES1 Standard met? 3Dilston College and the Registered Manager have provided impressive evidence that it takes swift and effective action to protect students in line with its own protection and whistle blowing policy and procedure; the ongoing complaint investigation referred to above has resulted in a referral to the national Protection Of Vulnerable Adults list.Dilston College Of Further EducationPage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Service users live in a homely, comfortable and safe environment. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. Service users toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? An inspection of the buildings was not carried out on this occasion; the college carries out its own inspection and audit on a regular basis and students are involved these inspections. Each part of the college is subject to a lot of wear and tear due to the number of students using it; standard repairs and maintenance are carried out regularly, and any matters relating to Health and Safety are addressed immediately.Dilston College Of Further EducationPage 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This standard was not assessed at this inspection. YES NO NO X X X X Standard met? 0 X XX X X XDilston College Of Further EducationPage 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence This standard was not assessed at this inspection. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Dilston College Of Further EducationPage 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? As there was not a full inspection of the building on this occasion, this standard could not be fully assessed. However, the college has maintained an impressive record of hygiene and cleanliness over several inspections.Dilston College Of Further EducationPage 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the homes recruitment policy and practices. Service users individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was assessed and met at the previous inspection.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This standard was assessed at the previous inspectionDilston College Of Further EducationPage 28 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme Key findings/Evidence X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXXStandard met?4The college has a mixture of care staff and tutors on duty; only care staff are relevant to this inspection report. The mixture of tutors and care staff ensures that students can receive effective, on going support. Each individual unit within the college has care staff on duty according to the assessed care and support needs of the students, the college would review staffing levels according to the levels of needs in each unit as the student population changes and develops. There are low levels of sickness and staff turnover at the college.Dilston College Of Further EducationPage 29 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Dilston College has a thorough and systematic recruitment procedure that seeks to support and protect students. Documentary evidence was seen regarding recruitment; for recently recruited staff two written references had been obtained and Criminal Records Bureau checks had been sought. Interviews are standardised and the thread of working towards equal opportunities is present in job descriptions and induction.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 4 Key findings/Evidence Standard met? The colleges training and development programme was commended at the previous inspection and this continues to be the case at this inspection. Training for staff is comprehensive and covers statutory training as well as training relating to the needs of students; the amount of training days for each member of staff far exceeds those expected by National Minimum Standards.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? This standard was not assessed at this inspection.0Dilston College Of Further EducationPage 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self- monitoring, review and development by the home. Service users rights and best interests are safeguarded by the homes policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. Key findings/Evidence NO 4Standard met?Management at Dilston College is strong, efficient and professional. The Management Team each have specific areas of responsibilities and each manager has demonstrated an impressive commitment and competency. There is continual evidence that the Management Team constantly reflects on its practice and develops ways of maintaining and raising standards.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 4 Key findings/Evidence Standard met? The management team at Dilston College have created an open, positive and inclusive atmosphere that clearly benefits students and staff; the management approach is professional, transparent and reflective ­ see standard 39. There is a Student Council the reports to the management team.Dilston College Of Further EducationPage 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 4 Key findings/Evidence Standard met? Dilston Colleges quality assurance and monitoring systems have been commended at previous inspections, and there is continuing evidence that these systems are used to maintain, reflect on and improve outcomes for students.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? All records inspected were up to date and satisfactory, these included: · Accident books · Fire log ­ including planned and spontaneous fire drills · Menus · Complaints · Significant incidents · Record of sanctions · Use of physical restraint · Kitchen routines relating to Health and SafetyDilston College Of Further EducationPage 32 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? All statutory training is complete and very much up to date. Maintenance of the environment is subject to robust, internal audit and on going consideration is given to security of the premises. There is an emphasis on Health and Safety at induction level, and this continues throughout all levels of the service.Standard 43 (43.1 ­ 43.7) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met? This standard was assessed and met at the previous inspection.Dilston College Of Further EducationPage 33 PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorBill MiddlemistSignature Signature SignatureRegulation Manager Gill Best Date Public reports 24/6/05It should be noted that all CSCI inspection reports are public documents.Dilston College Of Further EducationPage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 08 March 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Dilston College Of Further Education Page 35 Amendments to the report were necessaryYESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 22 July 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNONONOOther: No action plan was required.YESDilston College Of Further EducationPage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mrs Alison Sargent of Royal Mencap Society (Dilston College of Further Education) confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Dilston College Of Further EducationPage 37 Dilston College Of Further Education / 8th March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000000599.V143741.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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