Inspection on 08/02/06 for Lufton Manor College Of FE

This inspection was carried out on 8th February 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lufton Manor College Of FE 08/12/08

Lufton Manor College Of FE 22/01/08

Lufton Manor College Of FE 14/12/06

Lufton Manor College Of FE 09/05/06

Lufton Manor College Of FE 19/07/05

Lufton Manor College Of FE 22/02/05

Lufton Manor College Of FE 29/09/04

Similar services:

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

2 Perhaver Park

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

CARE HOME ADULTS 18-65 Lufton Manor College Of FE Lufton Yeovil Somerset BA22 8ST Lead Inspector Judith Roper Unannounced Inspection 8th February 2006 10:00 Lufton Manor College Of FE DS0000016084.V283252.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 Lufton Manor College Of FE DS0000016084.V283252.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. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lufton Manor College Of FE Address Lufton Yeovil Somerset BA22 8ST 01935 403120 01935 403126 tess.baber@mencap.org.uk H4037@mencap.org.uk Royal Mencap Society 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) Mrs Teresa Ann Baber Care Home 74 Category(ies) of Learning disability (74) registration, with number of places Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: Lufton College of Further Education is one of three specialist colleges that together form Mencap National College. All the Colleges offer the Mencap Essential Skills Award as their curriculum framework. Lufton offers full-time residential and day education for students aged 16-25 with learning disabilities. The College is registered for 74 residential students. It is located on two rural sites on the outskirts of Yeovil at Lufton College and at Manor Farm. The college provides a range of residential provision on both sites. Accommodation is tailored to meet students developing independence skills, and provide various levels of support. A third of students live away from the main site in semi-independent settings. The aim of the college is to prepare students for the next stage in their lives (Mencap). All students follow the Essential Skills Awards as their curriculum framework, which consists of four elements: daily living skills; personal care and presentation; community and leisure; and practical and vocational skills. The CSCI inspects the service using the National Minimum Standards that which applies to residential services for younger adults (Care Homes for Adults 18-65). However, as an educational establishment Lufton is also inspected by Ofsted. The CSCI reports should therefore be read in conjunction with the Ofsted reports to gain a comprehensive overview of the service provided. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previous inspection was announced and took place on 19 July 2005. At that inspection five requirements and four recommendations were made. Three Inspectors carried out this unannounced inspection. The inspection took place over three days from 8 February 2006. At the time of this inspection two requirements and two recommendations had been met. Seventy two students were residing on the main site and Manor Farm site. The inspection took place just before half term. A large number of students were spoken with. Some students were in the process of preparing for their return home for half term. The Inspectors spoke to a number of staff both in small groups and in private. Steve Robinson, Assistant Principal and other members of the management team were available during the inspection. Staff were observed being kind and supportive towards students. The Inspectors viewed most of the accommodation at the main house and Manor Farm. The Inspectors viewed records in relation to student portfolios, medication and health records, recruitment, health and safety records, quality assurance, and staff training. There were some students under the age of 18 resident at the college. This means that the college is also inspected against the supplementary standards of the National Minimum Standards for young people aged 16 and 17. The inspectors would like to thank students and staff for their involvement and participation in the inspection process. As a result of this inspection the college has ten requirements and fifteen recommendations. What the service does well: Students appeared very happy and enjoy their learning experience at the college. Some students commented that they had made new friends. A large number of students commented that Lufton College provides a variety of activities. The staff training and development programme is comprehensive and detailed with good records kept. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 6 97 of students commented that they enjoy the food at the college. A quality audit is kept of all accidents and incidents. Staff appear very positive and have a good awareness of student’s needs. What has improved since the last inspection? What they could do better: Lufton College has a number of requirements and recommendations that are detailed in the main body of this report. These include; • • • • • • • • Care planning, student’s personal and social support and healthcare needs. Medicines. Individual service users and environmental risk assessments. The general maintenance and refurbishment of the college. Staffing levels at weekends and evenings to promote further activities and staff supervision. Promoting service user’s privacy and empowerment. Promoting hygiene. Food safety management. Regulation 26 reports must be forwarded to the CSCI. 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. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Pre-admission assessments are comprehensible and detailed, carried out over several months to carefully assess whether the placement at the College is appropriate. Education and health care provision is personalised and holistic, although records identifying current health care needs to improve so that staff support for students is clearly directed in a written accurate plan. EVIDENCE: Three pre-admission assessments were seen within student portfolios. These included input from students, parents and staff. Students are allocated a tutor and key worker. They monitor the needs of their individual students and record progress toward individual learning plan goals. Tutors, key workers and the day officer (who has a responsibility for the overview of the health needs of the general student populous) monitor health care needs. However, this may be at risk of being hampered by the lack of written thorough health care and support plans that reflect current health care needs. (See Standard 6). Staff are trained in meeting the individual communication needs of students. Student progress is assessed at least termly. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 9 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 Individual student learning plans contain information on educational needs but do not contain information and clear guidance on how to meet student’s healthcare needs. Students are encouraged to make decisions and exercise choice. They are encouraged to participate in the day to day running of the college. EVIDENCE: Students have an individual learning plan at the college. This maps out objectives for students to work toward each term. Objectives are educational and lifestyle centred with students following a weekly timetable of the curriculum based on the Mencap Essential Skills Award. Each student has a basic care plan. Care plans viewed did not fully reflect the individual’s assessed health and social care needs. It was unclear how some students’ healthcare needs were to be met in relation to the management of epilepsy, continence, asthma and challenging behaviour. For example, for one student with epilepsy the plan stated that the student had the condition, but did not include what triggers this, how to manage it, or a record of seizures. An individual care plan Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 10 must be introduced to ensure each student’s needs are being met appropriately. Nevertheless, the care plan for one student with diabetes included very good detailed information and clear guidance. This had been drawn up with input from the Diabetic Nurse. It was noted that some care plans had not been signed by the students. It is recommended that wherever possible students are encouraged to sign their care plans. Students are encouraged to make decisions, wherever possible. A key worker is available to provide support. The student council meet weekly and are involved in the running of the college. Some students had risk assessments for bathing, COSHH and room sharing. One student who has epilepsy is living in accommodation away from the main house. There was no risk assessment to support this. Individual student risk assessments must be conducted where needed and reviewed appropriately. The college has policies and procedures relating to confidentiality and Data Protection Act 1998. Staff that the inspectors spoke to were aware of issues of confidentiality. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 The college provide students with a variety of leisure and social activities. However, this needs further development in relation to staffing and the access to remote controls in one accommodation area. It appears that at times students’ privacy is not respected and the college appears not to offer all students a key to their bedroom. Students are offered a choice of menu in the dining areas promoting their health and wellbeing. EVIDENCE: Students spoken to at inspection were happy with the activities provided, such as at the music club or the book club. Other activities include going to the pub, the cinema, bowling and a weekly disco. Some students and staff spoken to commented that additional evening and weekend activities were needed. At times this is restricted due to staffing levels. (This is further detailed in Standard 33). Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 12 Several students were keen to discuss their work experience placements that had been arranged with the support of the college. Students spoken to enjoy keeping in contact with family through letters and phone calls. Some students held their own key to their accommodation including their bedroom. This enabled them to come and go as they wished. Some of the students spoken to expressed a wish to have a key. Guidance and support for the use of keys should be provided to students to enable this if needed. The inspectors recommend that all students have the opportunity to have their own key. In one student accommodation the remote controls that operate the television/DVD were locked away. This was discussed with the senior management team. The college should ensure that students have access to such devices. Some students said that staff do not always knock before entering the student’s bedroom. This has been reported to senior management previously. The inspectors recommend that staff are reminded to knock and wait for a reply to ensure student privacy is respected. Meals are taken either in the student’s accommodation or in the main dining rooms. Some students are actively involved in weekly meal planning and shopping. Many students receive tutorial support in kitchen maintenance, hospitality services and food preparation as part of the college curriculum. The upgrade and improvements to the main dining area are due to start during half term. A new student questionnaire was distributed in October 2005. 97 of students said that they liked the food at the college. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 13 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 Key workers provide support to those students with personal care needs. Students have access to a variety of appropriate healthcare professionals. Medications are stored securely. The college must ensure that recording issues are addressed. EVIDENCE: Key workers support students with their personal care needs. Students spoken to confirmed that they have choice in what they wear and what time they get up and go to bed. All students have access to a variety of healthcare professionals. There is a designated day care officer who co-ordinates GP appointments and outpatient appointments where necessary. The inspectors have raised some issues relating to how the health care needs of some students are monitored. (This is detailed in Standard 6). Students are registered with a local GP during term time. The management team is planning more recorded clinical supervision and more meetings with the GP and pharmacist. Documentation was viewed Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 14 in relation to support one student was receiving from a Diabetic Nurse. There is speech and language and student counsellor support available on site. Each student has a medical overview form with a photo of the student. This identifies medical conditions, allergies, and requirements when administering medicines. Lufton College uses a Monitored Dosage System. Medication is stored in individual houses. One Medication Administration Record (MAR sheet) that was hand transcribed did not contain date of receipt of medication or quantity. There was no dosage or maximum dose stated for Paracetamol. Two MAR sheets that were not pre-printed had sticky labels. It is recommended that for all items without a pre-printed MAR sheet that a handwritten entry is made and that this entry is signed and dated by the person making this entry and be checked and signed by a second person. There was a daily record of the temperature of the fridge containing medicines. One inspector checked the balance of several medicines in stock against the record and these were correct. Some students are on a self medicating programme. The inspector viewed the recording systems in place to assess students ability to self medicate. The inspectors commented that when service users are deemed competent the college must complete individual risk assessments. On the day of the inspection it was noted that one service user’s medication was not located in their accommodation but at the main house. It is recommended that students who are self medicating have access to their medication in their own accommodation. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 15 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 The college has policies and procedures in place to safeguard students from abuse, neglect and self-harm. Mencap has a complaints policy and current complaints were being investigated following this protocol. EVIDENCE: Students knew whom to contact if they had any comments or concerns. Students had a ‘Dear Tess’ card if they wished to contact the principal. One inspector viewed the complaints log. There had been four complaints since the last inspection. Most complaints raised issues about personal care and support or lost student clothing at the College. The outcome of the complaints was not yet concluded. The College had responded to each complainant to acknowledge their complaint and to state that the issues were being investigated. The college has policies relating to adult protection, child protection, abuse, physical contact and bullying. The college confirmed that a copy of the revised child protection policy has been sent to the Area Child Protection Committee (ACPC) for comment. A POVA First check is received prior to a new member of staff starting work. The College has a statutory duty to inform the CSCI of incidents in the home under Regulation 37 reporting. The CSCI has been in dialogue with the College over the past four months in regard to the sharp increase in reporting of Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 16 incidents at the College relating to the health, welfare and safety of students. The management of the College has taken appropriate steps to address the issues flagged-up by the Regulation 37 reporting process. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Some of the student’s accommodation is homely and personalised. However, this is not the case for all students, as some areas do not provide a homely environment. Some accommodation is in need of urgent refurbishment and redecoration. These matters were discussed in detail with the senior management team. EVIDENCE: The inspectors viewed a range of student accommodation. This included lounge and dining areas, kitchens, bedrooms, bathrooms and toilets. Some areas were more homely and comfortable than others. The inspectors identified some areas that were not personalised and felt institutionalised. Lufton College has a planned maintenance and renewal plan. The inspectors observed a number of areas that were in need of major redecoration and refurbishment. It is strongly recommended that the college reviews its planned maintenance and refurbishment programme to ensure that all student accommodation is well maintained and furnished. The majority of students had a communal space within their accommodation. The students accommodated in Stable Block had to use the facilities within the main house. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 18 Improvements to the dining room in the main house are due to start in February 2006. Some students’ bedrooms were more personalised than others. A number of bedrooms were in need of redecoration. The inspectors viewed some shared rooms. The students sharing these rooms were around the same age and a risk assessment had been carried out. One student who was under 18 had sole use of a shared room. Some of the bathrooms had been decorated and made to feel more homely. A shower in one accommodation was out of use and awaiting repair. Liquid soap and paper hand towels were not provided in all bathrooms and communal areas. These must be provided in all bathrooms to control the spread of infection. The outer locks were broken in the bathroom and shower rooms in the main house. These must be repaired as this puts students at risk of being locked in and does not promote privacy. Several bathrooms did not have blinds. Students spoken to said they would like blinds for privacy. Students are responsible for keeping their accommodation clean. The key worker is responsible for ensuring cleanliness. During the inspection the standard of cleanliness within the accommodation varied. There are sufficient laundry facilities in the main house and within the student accommodation. Staff receive training in infection control and personal protective equipment is available. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 19 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): 32, 33, 34, 35, 36 Staffing levels appear to provide suitable levels of supervision for students most of the time. It appears there are sometimes insufficient levels of staff support at weekends. Staff recruitment records were complete and protect students from the risk of abuse. Induction training is comprehensive and detailed. The use of group inductions helps staff to become confident in their new role. Training is comprehensive. Risk assessments for pregnant staff were available but had not been updated. Staff have the opportunity to attend regular staff meetings. Staff supervision is currently not being carried out. EVIDENCE: There appeared to be sufficient staff on duty during the inspection. Staff who are in charge of students aged 16 and 17 are at least 21. Staff and some students spoken to felt staffing levels were insufficient at weekends. This means that staff on duty have less time to organise activities and spend time with students. The inspectors recommend that the management team review Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 20 staffing levels to ensure that students receive adequate support to meet all their needs, including leisure and social opportunities. Six staff recruitment files were seen. All files contained the required documentation as listed in Schedule 2 of the Care Homes Regulations 2001. The college’s application form should be reviewed, as the staff health declaration is brief with little detail. Inspectors discussed this with the management team. It is recommended that a more detailed health declaration be used. An induction programme was available. Training is carried out during the first three weeks of employment. The training includes manual handling, first aid, fire awareness, health & safety, child protection and medication. The child protection training meets the supplementary standard for students aged 16 and 17. The new staff had the opportunity to shadow the team. The college has a comprehensive training and development plan. 36 of staff had gained an NVQ in care. Twenty staff members are currently working towards an NVQ. The training and development plan includes targets in relation to staff completing NVQ qualifications. The nominated Lead Child Protection and Vulnerable Adults Coordinator stated that a training day was held and 177 staff received child protection training. Further child protection training has been organised. One inspector looked at three risk assessments for pregnant staff who are currently on maternity leave. There was an initial assessment but no evidence of reviews. It is recommended that these should be reviewed and updated on a regular basis, as per Mencap policy. Some staff spoken to stated that they have not received 1:1 formal supervision. It is recommended that this be addressed. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 21 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): 38, 39, 40, 41, 42 Staff and the Senior Management Team are approachable. The college does not promote health and safety in all of its accommodation. EVIDENCE: Students commented that staff are approachable. The vast majority of staff spoken to commented that senior management listen to staff and are approachable. Some staff that the inspectors spoke to confirmed that communication from the management team has improved. The inspectors discussed the need for a provider’s Regulation 26 report as covered in Standard 39. This must be submitted to CSCI every month as requested in December 2005. The home has policies and procedures in place to safeguard students. The child protection policy has been revised and is currently awaiting comment Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 22 from the ACPC. The records for the students aged 16 and 17 contain the information required by the Children’s Homes Regulations Schedule 3. At the previous announced inspection it was recommended that staffing rosters be maintained in each student accommodation. This would provide a clear indication of who is on duty at a particular location at anytime and indicates the support provided. This has not been addressed and remains a recommendation. Servicing records relating to fire safety are being maintained. The fire alarm system was tested during the inspection. The emergency lighting was last tested on 05/01/06. It is currently being tested six monthly but the management team advised that this will now be done monthly. A test for Legionella was last carried out on 14/01/05. Portable appliance testing is overdue. This must be completed to ensure electrical equipment is safe. There were no individual student risk assessments to identify environmental risks. Wardrobes were not secured to walls in all bedrooms to prevent crushing injuries. Radiators were not guarded to prevent burn injuries. The water supply was very hot in some bathrooms and presented a scalding risk. A risk assessment must be written to record risks and identify control measures. The windows on the ground floor in the Bungalow are not restricted. It is recommended that this be reviewed for security purposes and action taken if needed. Fridges are provided in the student’s accommodation. Temperatures were not being checked and recorded daily in all accommodations. The recorded temperature in one house was 11 degrees. Foods should be stored at a safe temperature (not more than 8 degrees Celsius). In one house, food in the fridge was out of date. Food should be disposed of when it passes the best before date to prevent food poisoning. Most chemicals in the laundry in the main house were stored in a locked cupboard. However, the washing machine has an auto dosing system and students can easily access corrosive chemicals. As the laundry was open, these should be boxed in to protect students from harm. Cleaning chemicals stored in student’s accommodation must be risk assessed. Staff receive training in health and safety including fire awareness and first aid when they start work at the college and on an ongoing basis. Accidents and incidents are recorded. A monthly analysis of accidents and incidents has been developed. This clearly shows the number and type of accident or incident. This is good practice. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 23 The college keeps birds and livestock on the farm. It is recommended that a policy for Avian bird flu be developed. Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 24 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 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X 3 2 3 3 1 X Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 25 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 YA6 Regulation 15(1) 12(1)(a) Requirement Care plans must include detailed information as to how student’s healthcare needs are to be met. These must be regularly reviewed. The college must ensure that those students with epilepsy or other health care needs who live in more independent accommodation have detailed risk assessments to address such matters and these are kept under review. The service must make arrangements for the recording and safe administration of medicines. The college must ensure that the shower that is currently out of use is repaired without further delay. The locks in the bathroom and shower rooms in the main house must be repaired to promote privacy. Liquid soap and paper hand towels must be available in all bathrooms and communal areas. A provider’s regulation 26 report must be submitted to CSCI every DS0000016084.V283252.R01.S.doc Timescale for action 17/04/06 2. YA9 13(4) 20/03/06 3. YA20 13(2) 13/03/06 4. YA27 23(2)(c) 30/03/06 5. YA27 12(4)(a) 13(4) 13/03/06 6. YA30 13(3) 22/03/06 7. YA39 26(5)(a) 08/03/06 Page 26 Lufton Manor College Of FE Version 5.1 8. YA42 13(4) 9. YA42 16(2h) 13(3) 13(4a) 10. YA42 13(4) month. Environmental risk assessments must be carried out relating to: • Radiators. • Cleaning chemicals. • Wardrobes. • Hot water supply. The service must ensure that food products including eggs do not exceed their use by date. Records of fridge temperatures must be kept in all accommodated areas and the temperature must not exceed 8 degrees Celsius. Portable appliance testing must be completed in all areas in order to promote health and safety. 31/03/06 08/03/06 08/04/06 Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 27 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. 2. 3. 4. 5. 6. Refer to Standard YA6 YA16 YA16 YA16 YA20 YA20 Good Practice Recommendations Students should be encouraged to sign their care plans. The college should ensure that students have access to the remote controls that operate communal televisions/DVDs. The college should offer a bedroom key to all students. Where this may not be appropriate this should be recorded in the individual person’s care plan. Staff should be reminded to knock on doors and wait for a reply before entering a students bedroom. The college should ensure that students who are self medicating have access to their medication in their own accommodation. It is recommended that for all items without a pre-printed MAR sheet that a handwritten entry is made and that this entry is signed and dated by the person making this entry and be checked and signed by a second person. It is strongly recommended that the college reviews its planned maintenance and refurbishment programme to ensure that all student accommodation is well maintained and furnished. Blinds should be provided in all bathrooms to promote privacy. The management should review staffing levels to ensure that students are offered activities at evenings and weekends. The health declaration that forms part of the staff application form should be more detailed. Staff should receive regular 1:1 supervision with their senior/manager. A staff rota should be maintained in each student accommodation. A policy should be developed for Avian bird flu. The college should review the need for the ground floor bedroom windows in the Bungalows to be restricted. This may promote security. Risk assessments for pregnant staff should be maintained and updated regularly following Mencap policy. 7. YA24 8. 9. 10. 11. 12. 13. 14. 15. YA27 YA33 YA34 YA36 YA42 YA42 YA42 YA42 Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lufton Manor College Of FE DS0000016084.V283252.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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