Inspection on 13/07/06 for Freeman College - 112 Brincliffe Edge Road

This inspection was carried out on 13th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Freeman College - 112 Brincliffe... 16/06/09

Freeman College - 112 Brincliffe... 03/07/07

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Freeman College - 112 Brincliffe Edge Road 112 Brincliffe Edge Road Sheffield S11 9BZ Lead Inspector Mr Rob Curr and Janis Robinson Key Announced Inspection 13th July 2006 09:00 Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Freeman College - 112 Brincliffe Edge Road Address 112 Brincliffe Edge Road Sheffield S11 9BZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0114 2965503 0114 2965541 none Ruskin Mill Educational Trust Mr John Edward Joseph Pickin Care Home 2 Category(ies) of Learning disability (2), Mental disorder, registration, with number excluding learning disability or dementia (2) of places Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users between the ages of 16 and 17 years may be accommodated. First inspection Date of last inspection Brief Description of the Service: 112 Brincliffe Edge Road is an annexe to Freeman College, which is part of the Ruskin Mill Educational Trust. The home offers residential accommodation and personal support to students. Individual bedrooms and communal living areas are provided. Two live-in house-parents staff the home. The house is situated within a short distance of the college, within a residential area. Annual fees range from £20.950 to £64.299 per annum. A student handbook is provided to all students. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. Two inspectors undertook a site visit, from 9.15am until 3.15pm on the13th July 2006. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, rotas, staff training and recruitment and fire records. Both of the house parents were interviewed about their knowledge, skills and experiences of working at the home. Discussions took place with the college residential services manager, who was present throughout this site visit. No students were present during this inspection, as the college had closed for the summer term and residential students had returned home. The inspectors would like to thank the staff for their support and commitment to the inspection process. What the service does well: What has improved since the last inspection? This is the first inspection carried out by the Commission for Social Care Inspection (CSCI). Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will 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. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A student handbook was available, which gave information about the college. However, no written statement of purpose or service user guide had been developed that gave specific information specific about Brincliffe Edge Road, to ensure students were fully informed before moving into the home. Whilst assessments prior to admission took place, to ensure the home could meet all identified needs, these did not contain the full range of information required. EVIDENCE: The inspectors examined the student handbook, which was provided to all students of the college. This contained a comprehensive range of information, and included information on college ethos, staffing and events. However, no written information, in the form of a statement of purpose or service user guide, was in place that specifically contained information on the registered establishment, Brincliffe edge Road. This information is important to current and prospective students, and their representatives, to ensure they are fully informed of their rights and obligations before choosing to move in. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 9 Assessments prior to admission took place, however, these did not include all of the information required to ensure all needs had been identified and could be reflected in individual care plans. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. 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. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans were in place for each student. These required further information to ensure all needs had been identified. Students were supported and encouraged to make decisions, to promote independence. Written risk assessments required expanding to ensure all risks had been identified and minimised. EVIDENCE: The inspectors examined one care plan. It contained a range of information and gave staff some information on how to meet individual needs. However, the plan did not provide detailed information on the specific action required of staff to ensure all individually identified needs were met. The plan did not evidence that it had been drawn up with the involvement of the student. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 11 A daily log was written by staff, this included information on aspects of the students life that was not reflected in the care plan. Discussions with care staff evidenced that students were encouraged and supported to make decisions as part of their daily life, and those decisions were respected. Some written risk assessments had been undertaken for students. However, these did not cover all of the areas identified in the care plan, such as health and safety and travel. These must be undertaken to ensure all potential risks are identified and minimised. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. 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. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All students had access to community facilities, and a range of activities were provided, to ensure students had a life outside of the home, and their interests were maintained. Staff encouraged students to participate in day-to-day activities. An open visiting policy was in operation, to promote contact between students and their relatives and friends. Staff respected students’ privacy. Students were encouraged and supported to be involved in the daily routines of the home, to respect their choices. A varied diet was provided to maintain health and accommodate individual preferences. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 13 EVIDENCE: The staff spoken with confirmed that students were able to go to the local shops and to access local facilities. A range of activities were provided, both in and out of the home, such as; music, board games, videos and trips to the local cinema and bowling alley. Staff confirmed that friends were able to visit the home, and residents could see them in private if they wished. Visits from family were welcomed, if these took place. Students participated in menu planning and some food shopping. A varied diet was provided and stocks of food were plentiful. Organic foods were provided at the home as a lifestyle choice and to promote the ethos of the college. Residents participated in the day to day running of the home as much as they were able, i.e. helping to wash pots, developing menus, and shopping for food. Staff could describe how they would respect students’ privacy. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. 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 home’s 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. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Personal support was provided to students as needed, to promote independence. Detail on the staff action required to meet personal support needs was not included in care plans. Students had access to the college GP, and homeopathic remedies, to maintain health. Individual health care needs and contacts had not been fully recorded to ensure these could be met. A medication policy and procedure were in place, to uphold students’ safety. Staff had not been provided with medication administration training to ensure they followed safe procedures. Medication records required reviewing to ensure they were up to date. EVIDENCE: The staff spoken with were able to describe how personal support was provided to those students that required this assistance. However, care plans did not provide detailed information on the staff action required to meet personal care needs. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 15 Health was promoted and maintained. Care plans contained some details of the health care professionals involved with the students. Full contact details had not been recorded on the plan checked. Students had access to the college GP, and homeopathic medication was promoted and provided as part of the college ethos. A policy on medication was in place and available to staff. Care staff assisted in the administration of medication, as required. However, staff had not been provided with training to ensure they were aware of safe procedures to follow. Details of medication in the care plan did not correspond with details of medication on the Medication Administration Records (MAR). Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A policy and procedure was in place, to ensure students concerns were listened to and taken seriously. Students had not been provided with the correct contact details of the local office of the CSCI. An adult protection procedure was in place, to protect students. Staff required training in adult protection, to ensure they had appropriate knowledge and were aware of the procedures to follow if an allegation was made. Staff had been provided with child protection training. EVIDENCE: A complaints policy was in place, which included detail on the steps to take to ensure any concern was taken seriously. Written guidance had been provided ton students, however, this did not include the contact details of the CSCI. The inspectors acknowledge that information was included in the students’ handbook; however, contact details were out of date. An adult protection procedure was in place and accessible top staff. Staff had not been provided with adult protection training. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. 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. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was comfortable, clean, and well furnished. Communal areas were homely and comfortable to provide students with a pleasant environment to spend time. EVIDENCE: An inspection of the buildings environment took place. The home was comfortable, clean and well furnished. Communal areas were well decorated and provided with pictures and ornaments to create a homely environment Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. 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 home’s 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. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Students benefited from the clarity of staff roles and responsibilities. National Vocational Qualifications (NVQ), were not available to staff, to improve their knowledge and skills. Recruitment procedures required some improvements to ensure safe procedures had been adhered to. Some training was provided to staff, however, training in moving and handling, and food hygiene was required to ensure staff had the basic skills required to carry out their duties. Support staff had not been provided with any structured induction training, to provide them with the basic information required to carry out their duties. Staff supervision, for development and support, did not take place at the required frequency. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 19 EVIDENCE: Staff had been provided with a written job description, and were clear about their own, and others roles within the organisation. The staff appeared to have the personal characteristics suitable for their role. They were motivated and good communicators. NVQ training had not been provided to any staff. Therefore the requirement to have 50 of the staff team trained to NVQ level 2 in care by 2005 had not been met. Whilst the organisation had a recruitment procedure, gaps in recruitment records evidenced that these procedures had not been fully adhered to. The inspectors examined two recruitment files. One file evidenced that gaps in employment history had not been explored. Two references had not been obtained. One file did not contain a reference from the previous employer. Information obtained from an application form did not correspond with that provided on a reference. Both staff had Criminal Records Bureau (CRB) checks undertaken. Staff were provided with some training. Refresher training was required for both staff to ensure their skills were maintained up to date. Staff induction took place, and both house parents spoken with confirmed that this included all of the relevant aspects. However, support staff were employed for one evening each week, these support staff had not been provided with the organisations induction training. Whilst staff supervision took place informally, structured formal supervision was not provided to staff. The inspectors acknowledge that a procedure for staff supervision was planned to be implemented in September 2006, records examined that these did not take place at the required frequency of six times each year. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. 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 home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s 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. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager’s leadership style benefited students and staff. The organisations quality assurance systems did not formally obtain the views of students. A health and safety policy was in place, to ensure staff and students safety. Systems were checked and serviced. Staff were provided with health and safety training. Additional training was required to ensure staff had all of the basic skills required to meet students’ needs. Support staff had not participated in a practice fire drill to ensure they knew how to respond in an emergency. EVIDENCE: Staff said the manager was approachable and supportive. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 21 Discussions with the manager evidenced that whilst the organisation had a quality assurance system, the views of students were not formally obtained via questionnaires. A health and safety policy was in place. Staff had been provided with health and safety training as part of the induction. Records examined evidenced that staff had not been provided with training in moving and handling or food hygiene. Fire fighting equipment was serviced. Weekly fire alarm checks took place. The two house parents had participated in a practice drill over and above the required frequency. However, support staff had not participated in any practice drill. Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4,5 Requirement A statement of purpose and service user guide, as set out in Standard 1 and Schedule 1, of the National Minimum Standards, must be developed and provided to students and their representatives. These must fully reflect the registered establishment. Needs assessments carried out prior to admission must contain all of the detail set out in Standard 2 of the |National Minimum Standards. Care plans must contain specific information on the staff action required to meet all identified needs, specific regard must be given to personal care needs. Care plans must evidence that they have been drawn up with the involvement of the student. All potential risks to the student must be identified, and a written risk assessment undertaken. All health care professionals contact details must be fully recorded. Timescale for action 01/11/06 2 YA2 14 01/11/06 3 YA6 15 01/11/06 4 5 YA9 YA19 13 13 01/11/06 01/11/06 Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 24 6 7 YA20 YA20 13 13,15 8 YA20 13 9 YA22 22 10 11 12 13 YA23 YA32 YA32 YA34 18 18 18 18 14 YA34 18 15 YA34 18 Records of contact with any health care professional must be maintained. All staff must be provided with medication administration training. A medication profile must be included in the care plan. Details of medication must correspond to those recorded on medication administration records. Consent to medication must be obtained from the student or their representative, and recorded. The complaints procedure provided to students must include the contact details of the local office of the Commission for Social Care Inspection (CSCI) All staff must be provided with adult protection training. Staff must be provided with access to NVQ training. 50 of the staff team must be trained to NVQ level 2 in care. Two written references, one of which must be from the last employer, must be obtained for all job applicants. All gaps in employment history must be explored. Records evidencing this must be maintained. All information provided on application forms must be cross checked to verify that it corresponds with information provided in references. Where inconsistencies are evident, these must be explored and explained. Support staff must be provided with the organisations induction training. DS0000065227.V302821.R01.S.doc 01/12/06 01/11/06 01/11/06 01/11/06 01/12/06 01/11/06 31/01/07 01/11/06 01/11/06 01/11/06 16 YA35 18 01/10/06 Freeman College - 112 Brincliffe Edge Road Version 5.2 Page 25 17 18 YA36 18 12 YA39 Formal staff supervision must take place a minimum of six times each year. The organisations quality assurance system must be expanded to formally obtain the views of students. The results of annual audits must be published and made available to students and their representatives. All staff must be provided with moving and handling and food hygiene training. Support staff must participate in a practice fire drill at least twice each year. 01/09/06 01/01/07 19 20 YA42 YA35 YA42 18 13,18 01/11/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Freeman College - 112 Brincliffe Edge Road DS0000065227.V302821.R01.S.doc Version 5.2 Page 27 - 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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