Inspection on 08/11/07 for Henshaw`s College

This inspection was carried out on 8th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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

Henshaw`s College 01/11/06

Henshaw`s College 14/03/06

Henshaw`s College 10/11/05

Henshaw`s College 20/01/05

Henshaw`s College 05/10/04

Henshaw`s College 15/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Henshaw`s College Bogs Lane Harrogate North Yorkshire HG1 4ED Lead Inspector Mrs Irene Ward Key Announced Inspection 8th November 2007 09:00 Henshaw`s College DS0000007884.V352973.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 Henshaw`s College DS0000007884.V352973.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. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Henshaw`s College Address Bogs Lane Harrogate North Yorkshire HG1 4ED 01423 886451 01423 885095 cliff.savage@hsbp.co.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) Henshaws Society for Blind People Mr Clifford Savage Care Home 65 Category(ies) of Learning disability (65) registration, with number of places Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 65 service users all of whom have a Sensory Impairment and may also have a Physical Disability. from 16 years to 25 years Date of last inspection 1st November 2006 Brief Description of the Service: Henshaws College is operated by Henshaws Society for Blind People and provides further education, personal care and accommodation. It is registered with the Commission for Social Care Inspection to provide personal and social care for sixty-five younger adults (college students) who have learning disabilities with an additional visual impairment and who may have a physical disability. Some students may be aged 16 and 17 years old. The College is situated on the outskirts of Harrogate close to local facilities in Starbeck and Knaresborough. The campus includes a central teaching block with refectory, sports facilities, and several purpose-built residential units. There are ongoing plans to replace all the residential units with modern facilities over the course of the next 3 to 5 years. All bedrooms are for single accommodation and each house has shared areas including a lounge, dining room and kitchen. Some meals are prepared and eaten in the college refectory. The campus has various grassed areas and several themed gardens all of which are well maintained. There is also ample hard standing for parking in an area close to the main entrance to the college. There is level and ramped access to buildings and some doors are automatic. The weekly fees on the 8th November 2007 range from the Learning and Skills Council rates which are annually from G £49,069.00 to exceptional £86,513.00 and do not include costs for hairdressers, some toiletries, chiropody, and some leisure activities not organised or delivered by the College. Students or relatives and other interested parties are able to have access to inspection reports by requesting them from the college. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is what was used to write this report. • • • Information about the college kept by the Commission for Social Care Inspection. Information asked for before the inspection, this is called an annual quality assessment questionnaire. Information from surveys that were sent to, students, relatives and care managers. Seven surveys were returned from students, four from relatives and one from a care manager. An announced visit by two inspectors to the college campus lasting six hours. A person, who works in the Information and Reporting team for the Commission, also accompanied the inspector on this site visit. This visit included a tour of the premises, examination of records, observation of care practices where possible and talking to students, care staff and management. • Looking at four students care files in detail. What the service does well: The way in which information continues to be gathered and kept about students means staff can provide support in a way that students need and prefer. It also means staff have in depth knowledge and understanding about each individual student and so encourages them to develop skills and experiences safely. The training staff completes when they first start work gives them a good grounding in understanding the needs of people with disabilities. The ongoing training staff are expected to complete means staff develop further in their knowledge and skills, which improves the quality of the support that students receive. The Quality monitoring systems that are in place are effective and gives students every opportunity for their views to be sought. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 6 Positive comments were made by students through surveys sent to them and conversations held with them at the site visit. Students made comments about the college such as: “Great” “fantastic” “having independence” “the staff are fantastic – they are fun to be around” “I make my own decisions and when staff support is needed I receive it”. “I enjoy it here” “ I enjoy doing what I do, I am having fun”. “I am in my second year and having a great time”. Relatives also made positive comments via surveys sent to them and said, “ I cannot fault the services that are provided by Henshaws” “ The communication between staff and parents is excellent. We are always informed of any changes or issues”. “ Henshaws has provided my relative with the support that is needed during the last two years and enabled my relative to become quite independent”. What has improved since the last inspection? The Quality assurance system that is in place has improved and is much more effective. It is based on seeking the views of students and measuring success in achieving the aims and objectives and statement of purpose set out by the college. The college management team monitors performance and are always looking at continuously developing systems in making sure that the needs of students are met which are central to the work they do. The college’s student involvement strategy is looking at employing an ex-student as a student liaison officer for 10 hours per week. This will give students another link for them to turn to when they may have issues that need resolving. The college has an ongoing refurbishment plan in place and the students accommodation continues to be upgraded. This continues to be for the benefit of students and makes sure that the college continues to meet the complex needs of some of the students attending college. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 7 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. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 8 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 Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 9 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 and 2. People who use the service experience excellent quality outcomes in this area. Students needs are properly assessed prior to being given a placement at the college We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The college’s Statement of Purpose and the Service User Guide has been updated to reflect the services and facilities that the college offers to prospective students and reflects the changes that have been made to the colleges accommodation. These documents also contain the philosophy of the college and how equality and diversity is promoted through everything that the college does. All prospective students are sent a “starter pack” which contains the statement of purpose, student’s charter, and staff information booklet. All documents are available in Braille, large print or on audio. All prospective students undergo a full multi-disciplinary assessment of their needs prior to being given a placement at the college. An assessment team does this. The marketing manager from the college arranges a 24hr Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 10 assessment for the student, which will also include an assessment by the occupational therapist. Once admitted into college the first term or six weeks is used as an ongoing assessment process for the new student to ensure the college is able to meet both their educational and care needs. Staff at the college complete a residential assessment for the student, which follows the college’s traffic light system. This is a system where student’s abilities are scored on a points system from one to ten. One indicates that the student requires more assistance and ten the least. The assessments seen were all comprehensive in the detail they provide about students and clear about their care needs. They also detailed how staff would assist students to be able to meet their care needs. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 11 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 and 9. People who use the service experience excellent quality outcomes in this area. The care provided to students was of a high standard and encouraged them to make their own decisions and promotes independence, choice and respect for individuals. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Every student has an individual care plan or student support needs document and a learning and achievement plan. The ones seen were comprehensively detailed. For students who are able to contribute to their care planning they are encouraged to do so. Some care plan’s seen had been written by students. Students care plans are written in the first person, which are “All about me”. The care plans of four students at the college were looked at. One of which was someone who was new to the college. Student’s needs are assessed and provided, using a person centred approach. Care plans contain information Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 12 about every aspect of the student’s life including areas for developing new skills. Where specific support is required this is documented step by step to make sure the support is provide exactly how the student wants and needs. Care plans are reviewed regularly. Also present were risk assessments with the purpose of supporting student’s to live as independently as possible with safeguards in place, these were reviewed regularly. Whilst staff were supporting students during the day it was clear they understood individuals needs. They supported people sensitively and encouraged them to make choices. Students looked well cared for and made positive comments about the care they received when spoken to and through the surveys that were returned. Students when asked what it was like being at the college said, “Great” “fantastic” “having independence” “the staff are fantastic – they are fun to be around” “I make my own decisions and when staff support is needed I receive it”. “I enjoy it here” “ I enjoy doing what I do, I am having fun”. “I am in my second year and having a great time”. During the discussions held with students when they were asked if there was anything they did not like about college some said, “ Getting up in a morning”. Comments received from surveys from relatives were also very positive about the college and made such comments as: “ I cannot fault the services that are provided by Henshaws” “ The communication between staff and parents is excellent. We are always informed of any changes or issues”. “ Henshaws has provided my relative with the support that is needed during the last two years and enabled my relative to become quite independent”. When asked what does the college do well? One parent said, “ Listens and discusses individuals needs well. Has always responded to my relative in the most appropriate way and has given them the care and support needed to become more independent”. Students confirmed that they hold regular house meetings to discuss things like Christmas and trips. Two of the students spoken with said that they were members of the student’s council. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16 and 17. People who use the service experience excellent quality outcomes in this area. Students whilst at college are able to make choices about their lifestyle and are supported by staff to carry these out. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Each student continues to have an individual learning and achievement plan, transitional passports have been introduced in addition to the student’s individual learning and achievement plan, and this work has already commenced and a completed passport was seen. The transitional passports included student’s educational, care and social needs. Students are able to take the passport with them when they move on and away from the college, which will help them in their next placement. The college continues to produce a document at half term that is similar to a newsletter, which contains the standard activities that are happening on Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 14 campus. These are then distributed throughout the college and onto each of the houses. Students spoken to on the day of the visit and confirmed that there is a wide range of activities available to them such as; going out to the pub, bowling, theatre, visiting Lothereton Hall-Tropical World, Manchester United Football Club, O2 festival, Karaoke on campus. Some students said that they were going to see the pop group Sugababes. Students continue to participate in the Duke of Edinburgh Award Scheme and the colleges Special Olympics. Students made positive comments about activities available to them and said, “Leisure is good you can go out on trips”. “Weekends are good we do different activities such as going into town shopping”. “We have student meetings every week to decide what we want to do and pick menu’s for the week”. “ I enjoy the evening because I think they are more relaxed and I like the weekend when I go out”. Two comments received which were not as positive one from a student who said, “At the weekend staff try to let us do what we want to do but sometimes if there is a shortage of staff it may not be possible”. The other was from a relative, who said, “Sometimes there may be an issue of staffing and this can effect what students would like to do. This was discussed with one of the house managers who said that there had been problems regarding staffing, however the college has addressed this by having a recent recruitment drive, this has lead to three new staff being appointed for one of the houses. The college has a refectory that supplies students with a varied menu. There is a hot plate where students can choose a hot cooked meal, such as chicken tikka masala, breaded plaice, vegetable lasagne and so on. There is also a deli section where students have choices of salads, cheese, coleslaw, jacket potatoes and so on. There is always a choice of sweet such as banoffi banana pie, baked rice with lemon and fruit trifle just being some of the sweets available daily. The college refectory also caters for students on special diets such as gluten free, halal diet and nut allergies. There are always two vegetarian options on the menu. There are also two choices at teatime meals. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 15 The individual houses are also provided with basic food supplies, usually three times a week with such foods as cereals, bread, milk and fruit. When students were asked about the meals provided at the refectory everyone said that the meals were always good. One student said, “The meals here at college are excellent”. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 16 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 and 20. People who use the service experience excellent quality outcomes in this area. Student’s personal and healthcare is provided appropriately and sensitively according to individual needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staff aimed to promote the independence of the students and to provide support in a sensitive manner. Students preferences as to how they wished to be supported were recorded within individual care plans. Students are encouraged to take responsibility for their own health care although support is provided for students to access a local GP, whilst in college. Appointments for chiropody, dentist and opticians are usually attended when the students go home. However appointments maybe made locally when really necessary. Students have also been encouraged and supported to access the local Advocacy Service. Both students and relatives spoke positively about the care provided at Henshaws and comments were made such as: Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 17 “The staff are caring, kind and helpful. They always patient and take time with my needs. The carers always listen to what I say and are always there to help and support me with my needs” “I am very happy at Henshaws College. I have become more independent and I have achieved many new skills. Mum and Dad are so proud of how well I am doing. I am confident in finding my way around college.” “My relative appears to be happy and Henshaws has provided a safe and secure environment for them”. “Our relative has gained so much confidence and is very happy and has become more independent”. “I am very pleased with the care and social support that my relative receives and would not hesitate to recommend Henshaws to others if they had a similar need as my relative”. “ The college continues to operate two medication systems. One is a monitored dosage system where staff have the overall responsibility for medication, whilst the other system is dispensed from a chemist as it comes, this is part of the students learning skills where they are supported in taking responsibility for their own medication. For students who are able to take their own medication all have been provided with a lockable drawer in their own room. There is a policy in place for the storage and administration of medication. The Medication Administration Records were up to date and well maintained. Medication seen on the houses was securely stored in a locked cabinet. The pharmacy responsible for dispensing medication inspects the college to make sure that medication procedures are followed and are safe. Care staff receive regular training regarding medication and have obtained the accredited Care of Medicines certificates that are held on individual staff files. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 18 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 and 23 People who use the service experience excellent outcome in this area. Students at the college have access to an effective complaints procedure and are protected from harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Students are provided with a complaints procedure, which is produced in different formats such as Braille, large print or audiotape. The complaints procedure is also summarised within the service user guide and service users knew whom they needed to speak to if they had a complaint and felt confident that any concerns would be addressed properly. Students said that they were happy to discuss any concerns they might have with staff. Comment received from students who said, “I talk to staff if I’m not happy”. “I can talk to any of the staff”. “If I got a complaint I go through the complaints procedure”. The Commission For Social Care Inspection has received no complaints since the last inspection. There is a complaints logbook on each of the houses. Where staff log any complaints made by students. There is also a student’s Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 19 complaints form that can be completed by individual students or a representative on their behalf. The college has received two complaints that have been investigated appropriately with satisfactory outcomes. There is a comprehensive policy and procedure with regard to adult protection and staff have a good awareness of this in the discussions that were held with them. Staff receive training in adult protection issues during induction and further training is organised by the college annually. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 20 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 and 30. Quality in this outcome area is good. Students live in a clean, comfortable and safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four of the houses were seen during this site visit. All of the accommodation was well maintained and clean. The college is continually up grading the accommodation to ensure that it meets the needs of students. The new build is due to be completed by early next year. Students were complimentary of the College accommodation. The communal areas such as lounges, kitchens and training kitchens were also well maintained. The décor and furnishings reflect a “young persons” type of household and some of the bedrooms seen had been personalised by students. Most bedrooms were large and have been adapted to accommodate students with physical disabilities. The houses seen have sufficient bathrooms and toilets that were clean and well maintained. Adaptations have been made in the new builds to accommodate students who Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 21 are wheelchair users. Each of the houses has level access. A range of maintenance checks is completed on a regular basis to make sure that the houses are safe and secure. Students spoken to on the day all said that they liked their rooms and the houses that they were sharing with other students. Henshaws College is in the process of completing a new building that is to be student’s accommodation. The new building will be ready to be occupied by students sometime in the New Year. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 22 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): 32,34 and 35. People who use the service experience excellent quality outcomes in this area. Sufficient staffing levels, proper recruitment procedures and good staff training meant that student’s needs were met and their interests were safeguarded. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The staff records of four staff including a recently appointed member of staff were looked at. All records showed completed application forms, two written references, CRB (Criminal Record Bureau) checks had been obtained. A POVA first check had also been carried out. The college has been experiencing some difficulty because of the shortage of care staff. This has started to be addressed by the recent recruitment drive by the College and the employment of new care staff. Staff rota’s were looked at and showed that there are usually between three and four staff on duty on each individual house. There is one staff that is on sleeping in duty on each house. There are two staff members on waking night duty for all of the campus. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 23 Staff training records examined showed a comprehensive training programme. All staff complete a college specific induction programme followed by Learning Disability Award Framework accredited induction within the first 6 weeks. The college continues to provide all the mandatory training that is required. A range of other training including health and safety training, visual impairness, care of medicines, psychological/physical intervention and equality and diversity is just some of the training available to staff. This provides staff with the knowledge and skills to perform their duties in a competent manner. Staff spoken to thought that the training provided is good and equips them to work with students with varying degrees of disabilities. The college holds a training file for staff. This identifies what training staff have completed and what training is needed. The registered manager carries out individual six weekly supervision for house managers and senior care officers who then supervise senior enablers and enablers. House managers also carry out self-assessment review reports annually on the progress of each individual house. Staff meetings are held regularly. Annual appraisals are also carried out for all staff working at the college. Comments from both students and relatives were positive about the standard of care provided by staff. One student said, “I enjoy working with the staff and the carers are very good at listening and I love coming to Henshaws”. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 24 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 and 42. People who use the service experience excellent quality outcomes in this area. The management of Henshaws College continues to make sure that students best interests are promoted at all times. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Henshaws College has a good and effective management team that continues to develop and promote good practice in the best interests of the students that attend the college. The ethos and philosophy is open and positive. Students, relatives and care managers commented highly about the college. An accident book is maintained in line with the requirements of Data Protection. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 25 Student’s finances were not checked at this site visit. Historical evidence from previous reports gives evidence that their financial interests are safeguarded. Effective quality assurance and quality monitoring systems are in place. The quality assurance manager produces an annual quality procedure and cycle report. The report looks at how the college continuously self-monitors its performance and reviews, actions and develops outcomes for students. The report details how the college monitors performance by the systems they have in place for monitoring quality for students on a daily, weekly, 6 weekly, termly, quarterly and annual basis. The college also seeks feedback from students, relatives and various professionals. The quality monitoring systems that the college has in place emphasises student’s participation at all times, which is central to the work that the college does. There is a student council at the college, which meets regular and minutes of meetings is taken. Minutes seen said that the council is for “standing up for students rights and getting the student voice heard”. The college’s involvement strategy is looking at employing a student liaison officer for 10 hours per week. This could be an ex-student from the college. House managers complete a self-assessment review report annually on the performance of each house. A self-assessment report on the college is also completed annually. The quality assurance manager also carries out spot checks on the individual houses in line with what is required by regulation. There is an Equality and Diversity Committee at the college with student representation. The college embeds equality and diversity throughout what the college achieves and through everything they do such as race, gender and disability equality schemes that the college promotes. Information provided from the (AQAA) Annual Quality Assurance Assessment and the examination of selected health and safety documents show that regular checks to electricity and gas and fire safety equipment are regularly undertaken. Record keeping is of a consistently high standard. Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 26 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 4 2 4 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 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 4 X 4 X X 3 X Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? 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. Refer to Standard Good Practice Recommendations Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Henshaw`s College DS0000007884.V352973.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!