Inspection on 16/02/08 for Glasshouse Project

This inspection was carried out on 16th February 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Glasshouse Project 29/01/07

Glasshouse Project 06/03/06

Glasshouse Project 18/08/05

Glasshouse Project 09/03/05

Glasshouse Project 15/06/04

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

CARE HOME ADULTS 18-65 Glasshouse Project Wollaston Road Stourbridge West Midlands DY8 4HF Lead Inspector Ms Linda Elsaleh Key Unannounced Inspection 16th January 2008 09:30 Glasshouse Project DS0000060987.V351137.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 Glasshouse Project DS0000060987.V351137.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. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glasshouse Project Address Wollaston Road Stourbridge West Midlands DY8 4HF 01384 399400 01384 399401 kim.emmerson@ghc.rmet@org.uk 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) Ruskin Mill Educational Trust Ms Kim Andree Emmerson Care Home 44 Category(ies) of Learning disability (44), Mental disorder, registration, with number excluding learning disability or dementia (44) of places Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 44 LD and up to 44 MD, of which may include services users aged between 16 and 17 years. Registration is subject to the requirements as detailed in our letter of 17 March 2004 to Mr Gush, being met by the 17 June 2004. 2 service users to be accommodated at: 234 Chester Road North Kidderminster DY10 1TE 3 service users to be accommodated at: 64 Gauden Road Pedmore Stourbridge DY9 9HS 2 Service users to be accomodated at: 118 High Street Wollaston Stourbridge DY8 4NY 4 service users to be accommodated at: Old Mill Farm Bromsgrove Road Clent DY9 9QB 4 service users to be accommodated at: Vale Head Farm Kinver DY7 5NJ 3 service users to be accommodated at: Vale Head Flat Kinver DY7 5NJ 3 Service users to be accommodated at: 1 Coalbourn Lane Amblecote Stourbridge DY8 4HQ 2 Service Users to be accommodated at: Glasshouse Flat C/O The Glasshouse College Wollaston Road Amblecote Stourbridge DY8 4HF DS0000060987.V351137.R01.S.doc Version 5.2 Page 5 4. 5. 6. 7. 8. 9. 10. Glasshouse Project 11. 12. 13. 14. 15. 16. 17. 5 Service Users to be accommodated at: Coach House C/O The Glasshouse College Wollaston Road Amblecote Stourbrdge DY8 4HG 2 service users to be accommodated at: 14 South Road Stourbridge DY8 3XZ 4 service users to be accommodated at: 4 Kenrose Mill, Kinver DY7 6LA 4 service users to be accommodated at: Woodfield New Wood Lane Blakedown Kidderminster 4 Service Users to be accommodated at: Harlestone House c/o The Glass House College Wollaston Road Amblecote Stourbridge West Mids DY8 4HF 2 Service Users to be accommodated at: 12 South Road Stourbridge DY8 3XZ The three bedrooms in the property known as 4 Kenrose Mill, which do not currently have washing facilities, are fitted with wash hand basins within 3 months of this registration. 29th January 2007 Date of last inspection Brief Description of the Service: The Glasshouse College is part of the Ruskin Mill Educational Trust. The College aims to meet the needs of young people between the ages of 18 and 25, whose needs cannot be met in mainstream colleges. Places are available for some students who are between 16 and 17 years old. There are opportunities for students to develop skills in various areas, including glass making, stone carving, green woodwork, basket weaving, photography, gardening and performing arts. The work undertaken at the college draws inspiration from Rudolf Steiner, John Ruskin and William Morris. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 6 All students are encouraged to discover their potential and creativity and to appreciate the cycles of nature. The college provides day and residential placements. Residential students are accommodated in houses that are situated in the community. Students are encouraged to play a part in the running of the household, including cooking and domestic duties as part of their preparation for independence. The college, including the houses, is registered as a care home for younger adults. As part of the range of provision of accommodation, the college also has independent training flats, where students have greater opportunities to develop life skills. Some workers are close by to provide supervision and support to these students. These facilities do not form part of this registration and are therefore not subject to inspection. The college provides a service for students with a wide range of needs and the fees charged for this service are based on the individual assessed needs of each student. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 7 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. This inspection was carried out over three days in January 2008. The purpose was to assess the college’s performance in meeting the National Minimum Standards for Care Homes in respect of the residential service it provides to students. The report is based on the findings of the information provided by the college, examination of relevant records/documentation, visits made to three residential premises, discussions with managers, staff, students and relatives and comments received in the questionnaires sent by Commission for Social Care Inspection. Plans for re-structuring the college were implement in September 2007 and the ‘house parent’ model being used has become established. The application to register the manager for this service has been approved by the Commission for Social Care Inspection (CSCI). What the service does well: What has improved since the last inspection? The college has improved the quality of the information it provides about its service to prospective services users and other interested parties. The standard of the decoration and furnishing in the students’ accommodation continues to improve. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 8 Students’ progress reports are provided in user-friendly formats and a more planned approach is taken about identifying the most appropriate accommodation for the individual student. They are actively encouraged to maintain contact with relatives and other significant people in their lives. Staff are also more involved in consulting with others about the needs of the students, where applicable. Staff are receiving more regular planned supervision providing more opportunities to discuss practice issues and areas for development. An additional counsellor has been employed to provide support to students. 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. The summary of this inspection report can be made available in other formats on request. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 9 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 Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is good. Prospective students, parents/carers and placing agencies are provided with the information they need to make an informed choice about whether the college is able to meet the individual’s needs. Prospective students’ individual needs and aspirations are included as part of the college’s assessment process. The 3-day assessment enables them to participate in this process and experience what residential life will be like. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose was reviewed in September 2007. It includes details about the Glasshouse College (the subject of this report) and its sister colleges in Gloucestershire and Sheffield. It contains general information about the referral and admission criteria. More detailed information has been produced for residential students about day-to-day living and a booklet with answers to some of the frequently asked questions (FAQ) is provided to students and parents/carers. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 11 The college’s assessment and admission process includes a day visit and a three-day residential assessment. A detailed summary of the prospective student’s education and residential assessment is available on the file. The college identifies what support it can provide and how it will assist the student to develop her/his life skills. The student is encouraged to participate in this process. The college does not accept requests for emergency placements. A neighbourhood head is allocated to a group of residential households and is responsible for ensuring the service meets the needs of the student. First year residential students, who expressed a view, stated they were informed about where they would be living by letter prior to commencing their placement. The Student Handbook (Service User Guide) contains information about the college and residential provision and how the student’s progress will be monitored and reviewed. It contains references to the college’s health & safety, complaints, disciplinary and other relevant procedures. Some first year students reported they did not recall being issued with a copy of this handbook. This was brought to the attention of the managers who stated the handbook is issued and discussed with the students as part of their induction to the college and would re-visit this with the students. The Student Induction Handbook reports there are opportunities available for students to move to alternative households based on their progress. It also states the student will “…stay in a household usually for the whole academic year”. Following concerns reported at the last inspection the college has made improvements to its decision-making process and recording systems for assessing whether a change in accommodation during term-time would benefit a student. Students appeared less anxious and reported they felt more involved in this process. Senior staff stated there continues to be a reduction in the number students who move during the academic year. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. The students assessed needs and personal goals are detailed in their individual care plans. Regular meetings are held with the student to discuss progress. Students would benefit from knowing how the college will support them to celebrate events that are important to them. Guidance and support is provided to students to enable them to make their own decisions and take appropriate risks. Staff should have a clear understanding of the college’s procedures for behaviour management to ensure students receive consistent support from all staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Detailed care plans are produced for each student based on the information received during their assessment. Frequent meetings are held with the Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 13 student and her/his key worker to discuss their individual care plan. The student’s weekly house report on their progress is produced in an easy to read format, with pictures and flowcharts. Regular reviews take place with the student, residential staff, college-based staff and any other relevant people to discuss overall progress. A copy of each review is held on the student’s residential and central file to enable ease of access to all staff involved in the student’s care. The Commission for Social Care Inspection (CSCI) received the following comments from two care managers: “Staff always include the necessary people who are important to the young person in her/his care planning.” “We have seen a great change in the young person’s confidence and independent skills.” Two students said they were concerned about how they will celebrate their forthcoming birthdays, but had not discussed this with staff. One student was anxious about whether s/he would be able to see her/his family. The college needs to ensure timely discussions take place about what arrangements will be made for individuals to celebrate important events in their lives. At times students display unacceptable behaviour. Staff reported that on such occasions neighbourhood heads are available to provide guidance and support. Some staff commented that, on occasions, they feel they are expected to take responsibility for addressing unacceptable behaviour a student has displayed while at college. Training in behaviour management is provided to staff, however, some staff stated they were unaware of any written guidance on behaviour management by the college. The college is advised to discuss its behaviour management policy and procedures with all staff and monitor how this is implemented. Written guidance and training in assessing risks are provided for staff. Individual risk assessments are carried out to ensure students are protected and supported to take appropriate risks as part of an independent lifestyle. For example a risk assessment for one student shows s/he is able to travel independently to and from college, but requires escorting on journeys to visit friends and other venues. The student said s/he was looking forward to going home at half term. S/he identified the stations where s/he needed to change trains. A risk assessment for this journey has yet to be carried out. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 14, 15, 16 & 17 Quality in this outcome area is excellent. Students are provided with opportunities for personal development and are supported to participate in a range of activities in the home, at college and in the local community. Students are supported to maintain positive contact with family and friends and to develop new relationships. Advice and guidance is provided to assist them to make informed decisions about their lifestyles. Students are provided with nutritious meals and information about the effect different foods may have on their health and/or behaviour. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 15 Personal development issues are discussed with students in their one-to-one sessions with their houseparents. These meetings include discussions about healthy lifestyles, developing practical living skills such as cooking and money management. A programme of the student’s daily routines and activities is available in her/his file and a copy is provided to the student. The college has improved the information it provides to prospective students about the lifestyle and facilities provided in residential accommodation. Students are encouraged to participate in stimulating and creative activities. They are discouraged from spending the majority of their leisure time watching television and playing with game consoles. Leisure facilities in the local community are used throughout the week and students enjoy evenings out with their peers and staff from other households. The majority of residential students spend the holidays with their family. The college provides students with opportunities to participate in cultural and art history trips. Students stated they participate in some household tasks and regular meetings are held with residential staff to discuss common such as daily routines, leisure activities and, where applicable, relationships and/or behaviour. Staff stated they are occasions when group meetings do not occur because of the group dynamics and one-to-one discussions prove more beneficial. The reasons for not holding group meetings are documented and reviewed. Surveys completed by students showed varying levels of satisfaction with the college’s consultation process. The majority of students interviewed reported good relationships with staff and felt they were appropriately consulted about different aspects of their daily lives. Neighbourhood heads regularly visit the households. The reports produced of these visits include discussions held with the students. Students continue to be supported to maintain positive relationships with family and friends. Records and correspondence on students’ files confirm regular contact is made with students’ relatives and the neighbourhood heads reported increased contact with relatives had proved beneficial to the students’ progress. The majority of relatives confirmed they were very satisfied with the service provided by the college. Students’ nutritional needs, likes and dislikes, are recorded on their care plans. Mealtimes are viewed as social occasions, providing students and staff the opportunity to discuss the day’s events. Meals are nutritious and well presented. The college continues to develop its provision of organic food and educating students about healthy eating. Comments received from students are more complimentary than at previous inspections and they appear to have a better understanding of the effect diet has on their health and/or behaviour. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 16 Individual health issues in relation to diet are monitored and a plan of action is agreed with the student. One comment received by the Commission for Social Care Inspection (CSCI) from a student reflects the overall responses received about the residential service provided by the college – “I like the house because the house parents are nice …the activities are great and so is the food and drink.” Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. Suitable systems are in place to meet student’s physical and emotional care needs. There are policies and procedures for the safe handling and administration of medication. However, all staff responsible for managing medication should be trained to ensure the wellbeing of the students is fully protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No students were identified as requiring assistance with personal care. However, some students do require prompting to maintain good personal hygiene standards. Students have access to community health care services and are registered with a local GP. Special support continues to be provided by the college doctor who visits weekly. Staff reported the recent introduction of a sexual health and relationship counsellor has proved beneficial for students. But considered Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 18 the current arrangements of one visit per month to be insufficient to meet the needs of the students who require this serivce. Medical details and current medication is available in the students’ files. These are reviewed regularly. A full time nurse continues to be employed by the college. She ensures the health care needs are appropriately addressed and provides training for staff in the safe handling and administration of medication. Records examined and discussions held shows some staff, who are responsibility for managing medication, have not yet received training. The entries on the medication administration record sheets (MARS) examined where found to be satisfactory and are audited regularly. Policies for health and medication are available and include procedures for monitoring the wellbeing of students who manage their own medication. The college needs to ensure written details of arrangements for receiving and storing medication (including controlled drugs) are available at all its residential premises. A procedure for managing medication on behalf of students during the college day has been produced. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. Students feel their views are listened to and acted on. The college has suitable policies and procedures in place for protecting students from abuse, neglect and self-harm and are cared for by staff trained in the protection of vulnerable people. However, to ensure the best interests of the students are fully protected the college needs to ensure its policies and procedures are followed at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 20 The Statement of Purpose contains brief information about how to make a complaint. No reference to this is made in the college’s General Introduction document, dated 2007, or Information Guide. Information is provided in the Student’s Handbook. All but one student stated they knew how to make a complaint and identified a staff member they would talk to if they were unhappy or had any concerns. A copy of the full complaints procedure is included in the ‘Student Protection Policies’ and these are accessible staff. The college should ensure appropriate information about how to make a complaint is made available to relatives, referring agencies and any other significant people or organisations. There have been improvements in the process for addressing complaints. For example detailed information is recorded about the investigation and outcome of a complaint made by a student. The introduction of a system for the evaluating complaints, received over a period of time, would assist the college in identifying any areas where action may be needed to reduce similar concerns being raised in the future. Students at the college are aged between 16 – 25 years. Senior staff confirmed the college has a copy of the Local Authority’s Adult and Children’s Safeguarding Procedures. The ‘Student Protection Policies’ makes reference to the Department of Health (DOH) guidance ‘No Secrets’, ‘Every Child Matters’ and other relevant legislation and good practice guidance. The college has two nominated Adult and Child Protection Officers. Discussions were held about ensuring the appropriate procedures are followed for referring allegations and/or concerns to the local authority. Senior staff stated there were no current protection issues or investigations taking place. The records of attendance held on staff files confirm training is provided in the protection of vulnerable people. A copy of the college’s procedure for reporting a student who is missing or absent without permission is available in the homes. Staff stated they were familiar with this procedure. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. The improvements made by the college ensure students are provided with a homely and comfortable environment in which to live. Suitable arrangements are in place for ensuring the premises where students live are clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The college has residential premises in the local area for small groups of students to live. The standard of decoration and furnishing in these properties continues to improve. The three premises visited were clean and comfortable. Students appeared proud of their contribution in keeping the ‘home’ they live in clean and tidy. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 22 The students expressed overall satisfaction with their accommodation and they have personalised their bedrooms. They are encouraged to respect the individual’s right to privacy. Therefore, bedroom doors are not routinely fitted with locks. The inspector was informed discussions are held about what action needs to be taken where this right is not respected. In some in cases this has included fitting locks to bedroom doors. Suitable pass locks are fitted to bathroom and toilet doors. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 & 36 Quality in this outcome area is good. The wellbeing and safety of students is promoted through the college’s recruitment procedures. The students are aware of the different roles and areas of responsibilities held by individual members of staff. Students individual and joint needs would be better met by staff who are provided with personal training and development programmes. Students benefit from the support the college provides to through regular staff meetings and individual supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Students understood the roles and responsibilities of different members of the staff team. The college employs 36 staff to provide care and support to residential students. Of these, three hold the National Vocational Qualification Level 2 or Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 24 above and ten (28 ) are working towards this qualification. The ratio of trained staff employed by the college is below the National Minimum Standards of 50 . However, they are working towards addressing this. Staff recruitment records are kept in good order and show that appropriate procedures are followed. Where applicable, risk assessments are carried out and strategies identified to ensure student safety is fully protected. The college does not use the services of volunteers within its residential provision. Staff reported the college continues to make improvements to its induction programmes for new staff and training courses in general. One worker stated – “We have received a high level of professional support during the last year.” Records examined show the majority of staff have attended health & safety training, which includes areas such as First Aid, Fire Safety and Food Safety. Training is also provided in safeguarding students from abuse, anti-bullying and managing challenging behaviour. Discussions held indicate that not all training attended by staff has been entered on their records. The college is advised to ensure individual training records are kept up to date. Each member of staff should be provided with an annual programme that meets her/his identified training needs, such as the safe handling and administration of medication and arrangements for attending training updates, where applicable. Individual supervision sessions are held and a signed record is kept of each session. It is advisable that the previous supervision record is re-visited at the following session to ensure any areas identified as requiring action are addressed in a timely manner. For example, one worker’s supervision record identified the need to attend training for managing medication, but subsequent sessions did not report on whether this had been addressed. Each week residential staff meet to discuss practice issues, areas for development and any concerns. Mixed responses were received about the quality of communication between residential college staff. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is good. Students’ benefit from a service that is run by a suitably qualified manager and stable management team. Students are confident their views underpin the college’s self-monitoring and development plans for the service. However, the college should review its own monitoring systems to ensure the assessment of its own performance is based on accurate information. The health, safety and welfare of students are promoted through the college’s policies and procedures. However, these need to be more closely followed in some areas to ensure students are fully protected at all times. This judgement has been made using available evidence including a visit to this service. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 26 EVIDENCE: A suitably qualified and experienced manager, registered by the Commission for Social Care Inspection (CSCI), is responsible for the running of the residential service. A stable team of neighbourhood heads manage day-to-day issues on her behalf. Regular management meetings are held to discuss student and staff issues, for which minutes are kept. The manager arranges to visit staff and students at least once in each term. The views sought by the college from the residential students and relatives were positive about the service being provided. The college is in the process of producing an annual development plan. Annual Review feedback forms are provided at each student’s review for parents and agencies to express their views of the service provided by the college. The neighbourhood heads report additional support provided to staff in maintaining students’ files and record keeping has improved the quality of the information kept on students’ progress. However, there are some shortfalls in the systems for monitoring the overall performance of the service. For example, an accident reported to CSCI under regulation 37 was not recorded on the accident records kept by the college. Incident records also showed appropriate reporting and follow-up information had not been forwarded to the relevant agencies in all cases. For internal and external monitoring purposes the college is advised to identify the premises where the student was living at the time the accident and/or incident. Staff stated regular checks and inspections are carried out on appliances and equipment. However, the records for checks carried out on the portable electrical appliances show these are tested every two years instead of annually. Regular fire safety drills are carried out with students. During a visit to one of the college’s most recent premises the inspector was informed a student is allowed to smoke in her/his bedroom following a satisfactory risk assessment. However, managers reported this is against college policy and would be discussed with the student and staff. A work sheet was raised for smoke detectors to be fitted prior to the students moving into these premises. The work was not carried out. Arrangements were made for this to be addressed immediately it was brought to the manager’s attention. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 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 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 4 12 4 13 X 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X 2 2 X Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The college should ensure all staff have a clear understanding of its behaviour management procedures and ensure students are provided with a consistent approach by monitoring how these procedures are being implemented. Each student should be aware of how they will be supported to celebrate important events in their lives. Staff responsible for managing medication behalf of a student should be appropriately trained. Safeguarding policies should be followed at all times to ensure the best interests of the student is fully protected and the relevant agencies notified and updated in a timely manner. Individual planned training and development programmes should be produced for staff to support them in improving their knowledge and skills in meeting the needs of the students. The college should review its systems for monitoring its DS0000060987.V351137.R01.S.doc Version 5.2 Page 29 2. 3. 4. YA7 YA20 YA23 5. YA35 6. YA39 Glasshouse Project 7. YA42 own performance to ensure its assessment is based on accurate information. The safety of students should be promoted by carrying out appropriate checks on electrical appliances. Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Glasshouse Project DS0000060987.V351137.R01.S.doc Version 5.2 Page 31 - 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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