Inspection on 06/03/06 for Glasshouse Project

This inspection was carried out on 6th March 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 24 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glasshouse Project 16/02/08

Glasshouse Project 29/01/07

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 Announced Inspection 06/03/06 10:00 Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 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.V278606.R01.S.doc Version 5.1 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.V278606.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glasshouse Project Address Wollaston Road Stourbridge West Midlands DY8 4HF 01384 399400 01384399401 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 Bernard Feehan 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.V278606.R01.S.doc Version 5.1 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 accommodated 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.V278606.R01.S.doc Version 5.1 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. 27/09/05 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. All students are encouraged to discover their potential and creativity and to appreciate the cycles of nature. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 6 The college provides day and residential placements. Residential students are accommodated in the community and on the fringes of the campus in houses that are run by care workers, who provide care and support to the young people placed with them. 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. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 7 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to assess the college’s performance in meeting the National Minimum Standards for Care Homes. This report is based on the findings of announced inspection that consisted of discussions with staff and students, examination of relevant records/documentation and inspectors’ observations. The inspectors received a good response to the questionnaires sent to students, their relatives and relevant professionals. The college has fully met five of the requirements made at the previous inspection. The inspectors’ discussed the college’s plans with the manager to meet the remaining requirements and those identified during this inspection. The manager is to be commended for the improvements that have been made to the service. This is evidenced in the college’s documentation and comments made by students, staff and parents. What the service does well: What has improved since the last inspection? A more active approach is given to encouraging prospective and current students to participate more fully in the development of their care plans. More opportunities have been created to consult with students about the general running of the ‘house’. More information is provided to staff in respect of meeting students’ needs. The nurse’s role has been developed to include more involvement with the residential provision. The implementation of the healthy living policy continues to progress and further progress is expected with the appointment of a Head of Nutrition. The home has reviewed its structures for exchanging relevant information and its recording processes. This is providing more continuity of care for the students. An audit of staff’s qualifications and previous training has been undertaken and suitable training programmes are being devised. New, bank and agency staff Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 8 are provided with basic information about the service and the ‘house’ they will be working in. An annual redecoration and maintenance programme has been produced for September 2005 to August 2006. 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. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 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.V278606.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 The Glasshouse College needs to provide more detailed information about its services & facilities in respect of its residential provision in order to enable informed choices to be made by students about where they will live. Prospective students’ individual needs and aspirations are included in the college’s assessment process. Arrangements are made for prospective students to visit the College. A 3-day assessment enables the prospective student to experience residential life at the college. EVIDENCE: The general Statement of Purpose for Ruskin Mill Educational Trust includes an outline of the Trust’s referral and admission criteria. The manager is aware of the need to localise the information in order to provide prospective students, their parents/carers and placing agencies with information specific to the service & facilities provided by the Glasshouse College. Information detailed in Schedule 1 of the Care Homes Regulations 2001 must also be included. The Student Handbook (Service User Guide) provides information about college life and the variety of workshops the students may wish to attend. It is presented in a colourful format with pages for students’ to keep their own records and comments. There is limited information about the residential provision and the philosophy of the individual ‘houses’. Hence, the college Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 11 needs to provide students with more information about its residential provision. The college has carried out a survey of students, parents/carers & professional agencies. The majority of people expressed satisfaction with the information provided to them by the college. The survey does not provide sufficient details to distinguish between information provided about the education and the residential provision. The manager stated different formats for providing information, such as a video and large print, were being explored as a result of this survey. The college does not accept requests for emergency placements. The selection of students’ files examined contain applications from referring agencies and included application forms and specific supporting information about the prospective student’s individual background, educational history, achievements & objectives, medical & psychological reports and reports in respect of their social and interpersonal skills. The college’s assessment and admission process includes a day visit and a three-day residential assessment. There are no written procedures for the residential assessment. The quality of information completed by residential staff varies. The college needs to provide guidance to staff and monitor the carrying out of assessments. Prospective students are more fully involved in the process. They are actively encouraged to participate in identifying and prioritising their care needs and developing strategies with staff on how these would be met. Where a place is to be offered to a prospective student, this is confirmed in writing. A copy of the letter is available on the student’s file. A Neighbourhood Head is allocated to a group of homes. They informed the inspectors that prospective students are made aware the home they stay at during the three-day assessment is not necessarily the one they will return to should a place be offered. During their time at the college students have planned stays in different ‘houses’. However, there are incidents where students have moved between several ‘houses’ at short notice. For example one student has been accommodated in four homes within five weeks and is due to move again. The number of moves does not promote continuity for the students. Neighbourhood Heads stated improvements in record keeping enabled movements between homes to be better planned and reduced the number of short notice/emergency changes in placements. The aim is to reduce these further, especially during term-time. Two students discussed their forthcoming moves with the inspectors. One student made a request to move because he did not like the location and was not getting on with another student. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 12 A record is kept of the reasons for changes and arrangements made for a introductory visit, in most cases. Once settled, the tutor discusses with the student how they are settling in. The information is kept on the student’s file, but is not easily located. The college is advised to keep a tracking form at the front of files to make this information easily retrievable for monitoring purposes. Examination of records in respect of the residential provision show there are occasions when the number of students accommodated exceeds the maximum registration of the home. The manager was informed the maximum number of students accommodated in each ‘house’ must not be exceeded and includes young people being accommodated as part of the assessment process. The manager stated he was introducing a system to ensure such incidents do not occur in the future. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 13 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, 8, 9 & 10 Regular discussions take place with students about their assessed needs and personal goals. These discussions also include agreements of how their needs are to be met. This is reflected in the student’s care plan, monitoring records and review documents. Student’s permission is sought before information about them is shared with others. However, the recording process needs to be reviewed to ensure confidentially is maintained for all students. The college needs to demonstrate how students are consulted about all aspects of life within the ‘houses’. Students are supported to take appropriate risks through the risk assessment process in order to develop their independent living skills. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 14 EVIDENCE: The inspectors examined the files of eleven residential students. Each contains a care plan. The key worker discusses care needs with the student and encourages them to identify any other areas they require support. Areas of priority are agreed and how these are to be addressed. Staff monitor and record the student’s progress on a daily basis. At the end of each term the key worker, personal tutor and the student discuss overall progress. The college has produced a review format to record these meetings that is easy to read and includes pictures and flowcharts. The “First Steps Assessment – The Journey to Independent Living” review document is kept on the residential and the centrally held files. When a student moves from one residential provision to another their residential file goes with them. In some instances the inspectors were unable to clearly identify the transfer of a student from a care to supported living plan. This is an area that needs to be addressed. The educational provision is provided with a copy of the relevant areas of the student’s plan to ensure a consistent approach is taken in meeting the student’s needs. The college is planning to introduce a similar process to encourage parents to follow the student’s care plan when s/he is with them. The majority of parents who responded to the inspection questionnaire stated they were satisfied with the service. Reports of annual reviews are available and include the attendance of significant people in the student’s life, such as parents, placing agencies and other professionals and advocates. The college survey of day & residential students show general satisfaction with the service. There is a Student Council where issues and ideas are discussed and brought to the attention of the relevant staff. The inspectors were informed students are encouraged to participate in discussions about the dayto-day living arrangements. Half of the residential students surveyed stated they would like to have “a greater say in what happens in the house”. The inspectors were informed students who live in ‘houses’ that accommodate assessment students are consulted prior to a prospective student being placed. A number of students informed the inspectors that they were unhappy with this arrangement. Records of ‘house’ discussions about group living vary and no evidence was seen of discussions with students with regard to accommodating prospective students during their assessment period. Staff may benefit from written guidance in facilitating and promoting students’ participation in ‘house’ meetings. Reports of visits made to the homes by Lead Workers and the Neighbourhood Heads include reference to discussions they have had with some of the students present during their visits. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 15 Written guidance is available to staff with regard to carrying out risk assessments. Individual and household risk assessments are carried out for each student and reviewed on a regular basis. Some of the risk assessments examined detail strategies for reducing risk of violent behaviour. Staff discussed how they support students to take controlled risks, such as using public transport on their own. However, not all risk assessments include information about how a risk is to be managed. Staff must ensure assessments are appropriately completed. The college has identified staff who require training and are making arrangements for this to be provided. Information on the majority of ‘household’ risk assessments, medical records and incident reports include details of all the students living in the house or involved in an incident. In order to maintain confidentiality the college must review its reporting processes. Since the last inspection the facsimile machines in some of the houses have been re-sited. The inspectors were informed the college is discussing with their telephone provider arrangements for the remainder of facsimile machines to be re-located in a more secure place. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 16 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): 11, 12, 14, 15, 16 & 17 Daily routines and opportunities for developing social and independent living skills are discussed with students. Staff support them to maintain positive relationships with their family and other significant people in their lives. Students are encouraged to participate in appropriate pursuits. However, they need to be provided with information about activities and consulted more fully about their individual interests. The college provides students with a healthy and varied diet. EVIDENCE: Staff and students regularly discuss personal development. Significant incidents are recorded and discussed with relevant people. Where applicable, risks assessments and care plans are amended accordingly. For example arrangements were being made for one student to attend a support group to help resolve some issues of concern. The majority of students stated they felt supported by staff. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 17 A programme of the individual student’s daily routines is available in each ‘house’ and includes their participation in various household tasks. The home continues to support students to access facilities within the local community. Support is provided for students who are attending external work placements. There are opportunities for paid work to be undertaken at the college in the evenings and weekends. The college employs Support & Attendance workers who are based on the campus. They provide students with advice and “sort out any problems and help you on your way” (Student Handbook). Students stated they felt they had a good relationship with these workers. This is reflected in the student survey and recent OFSTED report. The inspectors visited a selection of ‘houses’. In one ‘house’ a swimming trip had been planned for later that evening. The inspectors were informed students are encouraged to participate in stimulating and creative activities and discouraged from spending the majority of their leisure time playing computer games and watching television. Whilst the college’s survey indicated a high level of satisfaction with regards to activities, the responses made to the inspectors from residential students were mixed. Some students stated choice is limited and requests for alternative activities were often refused. Similar comments were reflected in the survey. Activities provided by the college and preferred activities need to be discussed in the individual ‘houses’ and a record kept of these discussions. A written policy about activities, including the provision of televisions, should be produced and provided to students and their representatives. Students stated staff provide them with support in maintaining positive relationships with their family and friends. The records show an increase in contact between staff and the students’ families. Examples were given of staff attending meetings with students and the parents. Each ‘house’ has a copy of the college’s healthy eating guide, recipe book and examples for menu planning. Students’ nutritional needs, likes and dislikes, are recorded on their care plans. The Neighbourhood Heads reported improvement in the monitoring of students’ diets. An example was given of the work being carried out with a student about the effect certain food has on their behaviour. Natural, wholesome and organic food continues to be purchased from the college shop. Mealtimes are considered a social occasion providing an opportunity for students and staff to discuss the events of the day. Students gave examples of meals they have prepared for themselves and others. Staff are provided with training in Basic Food Hygiene. Students are also given the opportunity to attend this training. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 18 The college has appointed a Head of Nutrition who is based at the Vale Head Farm kitchen. Responsibilities include running the basic catering skills training programme for students and developing the ‘seed to table’ curriculum. A preliminary report has been produced on nutrition and diet from information provided by the individual ‘houses’ and arrangements are being made to consult more fully with students and staff. The aim is to raise awareness of the benefits of using fresh ingredients and identify learning and training needs. Seven staff have recently attended training in diet & nutrition. Lunch is available during weekdays in the college coffee shop. This facility continues to be less popular with the residential students. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 19 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 & 20 Students are consulted about their care plans and how care, guidance and support is provided. To ensure students’ health care needs are fully protected all aspects of the college’s medication procedures must be followed and records completed. EVIDENCE: No students have been identified as requiring intimate care. Where applicable guidance and support is provided to students about personal hygiene. The college has improved the management of students’ health care needs. There is clear guidance for the exchange of information between ‘house’ staff, college nurse and Neighbourhood Heads. Arrangements are made for students to receive specialist support, such as appointments with speech therapists. Discussions were held with care staff and Neighbourhood Heads about how students are encouraged and supported to manage their own health care needs. This is reflected in the records and the inspectors’ discussions with students. The college has produced a policy for the care of students who are unwell. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 20 The policy and procedures for the safe handling of medication have been reviewed. These include information about herbal remedies, risk assessments for students who self-medicate and monitoring processes. Details of students’ medication are included in their care plans. Examination of the records found the college’s procedures were not being followed in all cases. For example records are not always kept of medication received by the staff or returned for disposal. Gaps in recording were noted on some medication administration records (MARS). Errors identified during this inspection were brought to the attention of the manager. Staff confirmed suitable arrangements are made for them to receive training in the safe handling of medication. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 21 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 & 23 Students are provided with opportunities to express their views and concerns, however, an effective recording and monitoring system needs to be implemented to demonstrate how concerns and complaints are monitored. The college has suitable policies and procedures in place to safeguard students from abuse and staff are provided with training in protection issues. EVIDENCE: The Statement of Purpose does not include arrangements for dealing with complaints. However, information is provided in the Student Handbook (with contact numbers). The college’s policy is included in the ‘Student Protection Policies’. The college does not have an effective recording system for complaints. Students who spoke to the inspectors identified people they would go to if they are unhappy or are concerned about something. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 22 The ‘Student Protection Policies’ refer to the Department of Health (DOH) guidance ‘No Secrets’, Safe Harm and Every Child Matters: Department of Health 2003 and relevant legislation and good practice guidance. Other policies are included such as whistle-blowing, anti-bullying, lone working and incident & occurrence reporting. The records show 18 staff have recently attended training in Adult Abuse & Protection. More than a third of the residential students are currently under the age of 18 years old. The college needs to ensure child protection issues are included in its training programme. Staff discussed the action they would take to report a student missing or absent without permission. Written procedures were not made available to the inspectors during their visit to the ‘houses’. Staff discussed arrangements for the safe-keeping of students’ monies/valuables. A written policy was not available. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 23 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): These standards were not fully assessed and will be reported on at the next inspection. However, the college has produced a maintenance and renewal programme for September 2005 to August 2006. EVIDENCE: N/A Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 24 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, 33, 34, 35 & 36 Students discussed their relationships with various staff, demonstrating that they are aware of the different roles and responsibilities. The development of individual supervision and planned training programmes show progress is being made to ensure students are supported by competent and qualified staff who are able to meet their needs. There are suitable policies and procedures for the recruitment of staff. However, the process must be completed prior to employment to ensure students safety and well-being is fully protected. EVIDENCE: Daily briefings are held on the college campus to facilitate the exchange of information between residential and education staff. Monthly residential staff meetings are held that include detailed discussions about care practices, areas of concern/development and used to deliver short training sessions. Records seen and discussions held show regular movement of staff between the ‘houses’. Such movements need to be monitored in order for any areas of concern to be addressed promptly. The manager is advised to develop a suitable system for tracking and monitoring movement of staff. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 25 A handbook containing general information about the residential provision is available for bank and agency workers, however it needs further development. The inspectors look forward to reviewing progress. The college has suitable procedures in place for recruitment and selection of staff. A checklist is kept at the front of files. The selection of files examined were well organised. The applicant is provided with information about the role of residential workers and confirmation of employment is provided to the applicant. There is evidence that POVA First checks have been made. However, new employees have commenced employment prior to receipt of satisfactory CRB Disclosures, which includes checks in respect of working with vulnerable adults & children (students under the age of 18 years). Records kept of the probationary period for new staff are incomplete. Attention needs to be given to ensure the college’s policy is implemented and appropriate records are kept. The college has recently introduced a programme for planned supervision sessions. The inspectors will report in detail on its implementation at the next inspection. Individual assessments of training and development needs of staff is in the process of being completed. The college has an in-house training programme and is arranging NVQ training for staff. Staff confirmed they are provided with relevant client-centred information and training. The college requires staffing agencies to confirm satisfactory checks have been carried out on the individual worker and provide information about her/his experience and training. A folder is available for agency staff in each ‘house’ containing basic information about the service and ‘house’. A brief report on the performance of individual agency staff during their shift is completed and forwarded to Neighbourhood Heads. The college is not currently using the services of volunteers in its residential provision. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 26 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, 38, 39, 40, 41, 42 & 43 Students are benefiting from a well run home because of the leadership, management approach and the plans implemented to improve the service. Students are consulted about their views on the way the home is run, however, this needs to be more formally documented. Students’ rights and best interests will be better safeguarded through suitable policies and procedures that are age appropriate for the students (those under & over 18 years of age). Recordings made by staff must safeguard student’s confidentiality. The college has procedures and systems to protect the safety of students. However, it needs to ensure staff are competent in identifying hazards and producing suitable risk assessments. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 27 EVIDENCE: The manger continues to work on strategies for developing the service. Examples of this include the recently implemented planned supervision programmes. In addition, he has been instrumental in the revision of care plans, the content and re-structuring of students’ files. There is evidence to support the manager’s commitment to the professional development of staff. He provides a clear sense of direction and leadership which staff and students are able to relate to the aims and purpose of the service. Feedback confirmed consultation takes place with staff and students about service development. The manager confirmed the college does not yet have comprehensive quality assurance and quality monitoring systems. A programme of visits to report on the conduct of the ‘houses’ has recently been introduced. The persons nominated to carry out these visits should not be directly involved in the management of the ‘houses’. Systems need to be produced to enable the effective monitoring and reviewing of records, such as occurrences and complaints. Surveys are carried out with students, their parents and other significant people on an annual basis. An annual service development plan needs to reflect the aims and outcomes for students based on a systematic cycle of planning-action-review. The college is reviewing its policies and procedures. The Student Protection Policies have been reviewed. Attention must be given to ensuring relevant policies and procedures are available for students under 18 years of age and staff are aware of and understand these. Generally the standard of record keeping has improved. However, as previously reported, inspectors found some omissions in recording and some incidents where confidentiality of the students were not being observed. There are suitable health & safety policies and procedures. Programmes are in place to ensure regular checks and servicing is undertaken on equipment and facilities. Records are kept of environmental risk assessments carried out in each of the ‘houses’. However, the lack of cable management in some of the ‘houses’ increases the risk of trips. The inspectors were also concerned about the number of portable heaters being used. These have not been included in the risk assessments. The observations made, discussions held and records examined indicate plans are being implemented for the further development of the service. No concerns were brought to the inspectors’ attention with regards to financial matters. Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 28 Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 29 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 3 3 2 4 4 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 4 32 2 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 2 2 2 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 4 2 2 2 2 3 Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 30 Are there any outstanding requirements from the last inspection? YES 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 CH3YA42 Regulation S.24 CSA 2000 Requirement The college must not provide accommodation for students above the maximum registration number for each ‘house’ The college must produce a Statement of Purpose that contains all the required information, including what it specifically sets out to do for students under the age of 18. Timescale for action 05/05/06 2 YA1 4 28/07/06 (Previous date for compliance, 31st December 2004, not met) 3 YA1 4 The college must provide each young person with a Service User Guide that contains all the required information and in a format accessible to all students (Previous date for compliance, 31st July 2005, not met) 28/07/06 4 YA1 4 & 18 The college must produce a written procedure for managing referrals, assessments and admissions The college must review the information provided to representatives’ of prospective students to ensure it meets NMS DS0000060987.V278606.R01.S.doc 28/07/06 5 YA5 15 31/07/05 Glasshouse Project Version 5.1 Page 31 5.2 (contracts). (Not assessed at this inspection) 6 YA6 15 The college must ensure records clearly indicate the status of the student (care or supported living) The college must ensure records are kept of consultation with students with regards to: • day-to-day living arrangements within ‘houses’ • movement of students between ‘houses’ • the development and review of the policies, procedures and services. (Original date for compliance, 15th July 2005, not fully met) 30/06/06 7 YA8 15 & 16 28/07/06 8 YA8 24 The college must demonstrate how they consult with students about accommodating prospective students during assessments The college must ensure all risk assessments are appropriately completed The college must review its recording processes to ensure confidentiality is maintained Students and their representatives must be made aware of the college’s arrangements for televisions in its individual homes. (Previous date for action, 25th January 2006, not met) 28/07/06 9 YA9 13 & 32 28/07/06 10 YA10YA41 12 28/07/06 11 YA14 16 28/07/06 12 YA14 16 The college must consult & record discussions with students DS0000060987.V278606.R01.S.doc 28/07/06 Glasshouse Project Version 5.1 Page 32 about preferred activities 13 YA20 13 The college must take action to ensure its medication procedures are followed and all records are appropriately completed The college must: • produce information for parents and other relevant people about how to make a complaint and how this will be dealt with • develop a system to enable the effective monitoring of complaints to take place The college must ensure all staff receive child protection training Policies & procedures in relation to absences without authority must be kept accessible for staff (Original date for compliance, 1st July 2005, not fully met) 30/06/06 14 YA22 22 28/07/06 15 16 YA23 YA23 32 13 28/07/06 28/07/06 A policy and procedure on the safekeeping of students’ money & valuables must be made available 17 YA26 16 Suitable locks must be fitted to bedroom doors and students provided with the key for their room. (Unless a risk assessment has identified this is inappropriate) (Not fully assessed at this inspection) 28/07/06 Lockable facilities must be provided in students bedrooms and the key provided. (Unless a risk assessment has identified this is inappropriate) (Not fully assessed at this inspection) Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 33 18 YA32 18 A training programme that meets with the Sector Skills Council for Social Care must continue to be developed. 28/07/06 (Original date for compliance, 31st December 2004, not fully met) 19 YA34 19 The manager must ensure satisfactory CRB Disclosures are received prior to the employment of staff Staff must receive at least six planned and recorded supervision sessions each year and an annual appraisal. (Original date for compliance, 31st December 2004, not fully met) 05/05/06 20 YA36 18 28/07/06 21 YA39 24 & 26 A system for quality assurance & monitoring must be produced. Arrangements must be made to carry out visits to the homes, in accordance with Regulation 26Visits by Registered Providerreports prepared and copies forwarded to CSCI. (Original date for compliance, 31st December 2004, not met) 28/07/06 22 YA40 18 Policies & procedures, listed in Appendix 3 of NMS and any relevant policies & procedures for young people under the age of 18, must be available in the homes. (Previous date for compliance, 30th June 2005, has not been met) 28/07/06 23 YA42 13 The manager must ensure; • risks are identified, monitored and managed in a timely manner 28/07/06 Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 34 • risk assessments must be carried out by staff competent to do so 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 YA3YA6 Good Practice Recommendations The manager is advised to develop a tracking system to enable effective monitoring to take place of students movements between ‘houses’ The manager is advised to produce written guidance for staff in facilitating ‘house’ meetings and promoting students’ participation The manager is advised to develop a system for tracking & monitoring staff movement between ‘houses’ 2 YA8 3 YA33 Glasshouse Project DS0000060987.V278606.R01.S.doc Version 5.1 Page 35 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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