Inspection on 15/01/08 for NASH FE College

This inspection was carried out on 15th January 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

NASH FE College 12/12/08

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 NASH FE College Nash FE College Coney Hill Education Centre Croydon Road Bromley Kent BR2 7AG Lead Inspector Miss Rosemary Blenkinsopp Key Unannounced Inspection 15th January 2008 10:00 NASH FE College DS0000070229.V352587.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 NASH FE College DS0000070229.V352587.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. NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service NASH FE College Address 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) Nash FE College Coney Hill Education Centre Croydon Road Bromley Kent BR2 7AG 020 8462 7419 020 8462 0347 www.grooms-shaftesbury.org.uk Grooms-Shaftesbury Angela Maxine Crooks Care Home 43 Category(ies) of Learning disability (43) registration, with number of places NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 43 26/06/06 Date of last inspection Brief Description of the Service: Nash College is part of the Grooms-Shaftesbury and is a Further Education establishment for younger adults with a complex range of sensory, physical and learning difficulty needs. The College provides accommodation for 43 students to board through the week and a limited amount of respite care during the college holidays. Due to the percentage of students requiring personal or nursing care the College is required to be registered as a Care Home for Younger Adults under the Care Standards Act 2000. The College offers courses over a three-year period aimed at enhancing and promoting their students communication and life skills. The College is subject to inspection from both the CSCI and Ofstead. The fees are £125,000.00 per annum. NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors conducted an unannounced site visit. This was on the second week of the spring term. The College had forwarded the AQAA, which was well completed and provided good information for the preparation of the inspection. The two inspectors focused on different areas of the key standards including record keeping, staffing, health and safety as well as quality assurance. Feedback from students themselves was limited therefore signs of well being staff interaction and evidence of positive engagement with students was noted. Comment cards were provided at the site visit, as immediately preceding the inspection, the College had been on the Christmas holiday. Comment cards were left for care managers, relatives and other multi- disciplinary agencies for feedback on the service. During the site visit the inspectors met with senior staff of the College and other staff members and their feedback is included in the body of the report. Staff personnel files including recruitment and training were inspected. The two inspectors interviewed several members of the staff team. A limited tour of the premises was undertaken. In general many areas had improved, particularly those areas that had in the past caused concern i.e. documentation and medications. It was evident that the College had worked hard on staff training and ongoing efforts to recruit a full complement of staff continue. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcome. What the service does well: The College provides residential and educational facilities for some of the most profoundly disabled students. The students have learning disabilities as well as other problems including physical and mental health. The multi-disciplinary team on site provide good support within an educational and residential setting. Students within the College are enabled to make choices and be as active in the decision making process as is possible. Engagement within the local community is facilitated. The prospective students are subject to robust assessment procedures and this provides the staff team with good information on which to base thie care and NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 6 initiate a care plan. New students have a five day induction in the College before the other students return, allowing time to familiarise themselves with the College. Care plans and supporting risk assessments are designed around the individual’s needs. These were comprehensive and utilised the skills, knowledge and expertise of the whole multidisciplinary team to address care needs. The inspectors found that all of the documentation was well laid out and easily accessible. Staffing levels are maintained with a high ratio of staff to students Staff are well supported with training supervision and in house expertise. What has improved since the last inspection? What they could do better: There was evidence that some of the areas of medication practice need to be reviewed including the administration of medications. In addition records relating to Controlled Drugs must be fully completed. The care plans supporting risk assessment and other relevant information whilst comprehensive, is cumbersome and it would be impossible for new staff to absorb. This is particularly important as the College uses agency staff and amongst these qualified nurses. The College should review the level of information that a qualified nurse needs to be familiar with in order to be competent in thier role. It was related to the inspector that there was some of the basic equipment, which was not functioning including the blood pressure machine and the NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 7 thermometers for taking student temperatures. These must be available and in working order. 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. NASH FE College DS0000070229.V352587.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 NASH FE College DS0000070229.V352587.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective students are provided with information regarding the College, subject to robust assessment procedures and have an opportunity to sample the service prior to placement. The comprehensive assessment procedures ensure that the College are able to meet all of the student’s needs. EVIDENCE: Entry to the College is by way of application. Students and their families are provided with pre entry information packs, which gives an outline of the College and the services it provides. All prospective students are assessed over a two-day period at the College. The assessment is undertaken using a multidisciplinary team approach, who are on site in the College. The multi disciplinary team identify not only the care needs but also any equipment, which will be required whilst the student is at Nash College. This also provides students with an opportunity to sample College life, as many of them have not been away from home prior to this. If there is an opportunity, staff visit students in their current environment to gain further information to input into the assessment process. Following the two-day assessment a meeting is facilitated with the student, parents/carers and key members of the team, where an open discussion on the placement would take place. NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 10 Once the assessment has been concluded, and the College are satisfied that a placement can be offered, a contract is issued. The contract is in symbol form and where possible the student will sign it or their next of kin. Once accepted into the College, students are subject to a six week multidisciplinary team assessment following which, a review will take place. During this review the student’s needs, choices, aspirations and hopes are formulated in to support and learning plans. The Statement of Purpose was available in the hall. Information is made available in other formats such as symbols. NASH FE College DS0000070229.V352587.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans are in place, which address the care and educational needs of the student. The care plans are formulated using a multidisciplinary approach and contain a good standard of information, which enables staff to provide individual care to the student. EVIDENCE: Within the College it is not only the care needs of the student, which need to be addressed, but also the main purpose of the placement is education. Within the College there are 90 of students who require a health care plan as well as a plan around learning objectives. There are several areas, which need to be routinely incorporated in to care plans including manual handling. Each student has an eating and drinking assessment and protocol in place. The inspector selected two care plans for inspection. The content of the information recorded within them was to a good standard and evidenced that NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 12 the students have their healthcare needs assessed and addressed. Individual plans are reviewed at the end of each half term and on an annual basis where objectives and achievements are assessed. In the first care plan the student had a severe learning disability, epilepsy and was said to display challenging behaviour if they are exposed to any foodstuff that contains beta carotene. There was a good behavioural management program in place to address this. In the second care plan selected for inspection the student also had a diagnosis of learning disability, scoliosis and had a spinal rod fitted. There was a very good needs assessment with moving and handling assessments. Multidisciplinary input in to the care plans provides comprehensive health care. Reviews of care can be arranged at any time. Formal reviews are held with the student their families and multidisciplinary staff. Risk assessments are in place to address the individual’s needs, and these include use of transport, kitchen equipment and activities. The College has good support from the multi disciplinary team and the visiting GP. Students are encouraged to be part of the decision making process and communication aids assist with this. NASH FE College DS0000070229.V352587.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The College provides opportunities for educational and personal development in a supported setting. Students are assisted to engage with a variety of internal and external leisure opportunities. Meals provide a choice of healthy options. EVIDENCE: The College supports students to engage in the local community. There are mini buses available for outings and there are plans to increase the number of drivers to provide more opportunities. There are plans to provide some students with travel passes where assessed as appropriate. The College organises evening and weekend events for students and some students are part of local clubs. Students have a weekly meeting, which provides students with a say in how the College is run. The College monitors the ethnicity, gender and disability of NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 14 students and staff. The College celebrates multi-denominational festivals. In July the arts festival included an African Dance group as well as other entertainment. Holidays are arranged for students with the most recent having been a boating holiday. Family contact is encouraged and visiting is flexible. There are a number of forums that offer students opportunities to engage with the service. These included residential meetings, the student union, class group meetings and surveys. The inspector saw the minutes of a student meeting, which were in symbol form. These were nicely presented and easy to extract information from. The College have a strong Christian Union group. The College is currently in discussion with Bromley Advocacy Service to look at ways of developing self-advocacy. Work experience is undertaken both within the College and through external avenues. The lunchtime period was observed. It was a busy and noisy period. The majority of students require assistance or supervision with their meals. The meal arrangements were discussed with the Principal who had reviewed meal times, unfortunately this had impacted on other activities including classes and therefore it reverted to the original times. The menu was on display. The meal offered a hot vegetarian meal as well as beef stew and dumplings. Jacket potatoes were also available with a selection of vegetables and salads. There was a choice of desserts including fresh fruit and yogurts. The menu reflected healthy eating as well as choice. The meals also catered for those students who required pureed food. Adapted cutlery and plate guards were in use for some students. Staff were observed to assist students they demonstrated great patience and the meal was unhurried. NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Students are provided with a comprehensive package of support and care form the multidisciplinary team that is based on their individual needs. Medications are safely managed. EVIDENCE: Personal support needs are set out in the care plans and prior to starting College any equipment necessary is provided. The support plans are specific to the individual student and detail the assistance required with activities of daily living. The College has the benefit of the multidisciplinary team on site who provide professional input. Preferences regarding gender care are addressed. The College has a sick bay in the nurse’s area. Students are registered as temporary residents with a local GP during term time. In the last twelve months the multidisciplinary team has been expanded and now includes a Psychologist and a Consultant in Epilepsy. The lunchtime medication administration was observed. This medication round takes approximately and hour and a half with others taking over three hours. The dining room was very noisy with a lot of activity. One trained nurse NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 16 administered the medications. It would be extremely difficult to concentrate for the period of time required to administer medications particularly with the levels of noise and activity. The students in this College can be receiving complex medication regimes. The College has had three medication incidents. The inspector was advised that the College has had an external body reviewing the practices around the administration of medication. The inspector recommends that the College review the practice of administering medication, perhaps with two trolleys and two staff administering them. The practices must afford greater safety for students, staff and all concerned. Medication charts were fully completed with photographs of the student known allergies and specific protocols for administration of medication. The medication charts were completed with medications received recorded. The College has a number of controlled drugs in use. These are checked three times daily. The amounts in stock were checked and correct. The storage of these medications was in the appropriate lockable facility. The records relating to controlled drugs were also inspected. In those cases where controlled drugs are taken out with students, as part of community activities, there was only one staff signature. On questioning this, the inspector was advised that the time the students’ return is when only one qualified staff is on duty. Two signatures are required for all controlled drugs. The inspector checked that food supplements in use and found two had expired. The qualified nurse had also done an audit of these and found several to have been past their use by date. The qualified staff stated that as it was the beginning of term these had been received from pharmacy already expired. This needs to be rectified. The inspector also advised that in light of current legislation namely the Mental Capacity Act that the home should be devising a covert administration policy based on the guidance produced by the NMC and the British Pharmaceutical Society. Within the College qualified nurses administer the medication. Whilst it is accepted that nurse are trained in medication procedures within this College the amount and complexity of the medications is unique. It is recommended that all nurses undergo specific medication training and receive regular updates on this, along side proficiency tests. Please see requirement 1. Please see recommendation 1 and 2. NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Students can be assured that all complaints and allegations of abuse are taken seriously, fully investigated and the appropriate action taken. Staff were knowledgeable about the actions to take in such an event and supported by specially trained staff. EVIDENCE: The College has a complaints procedure, which is comprehensive in content and available in other formats. The complaints policy details time frames for action with twenty days as the response time. The organisation has a whistle blowing policy also in operation. On previous occasions the CSCI has found the College to be open and transparent when dealing with any complaints or concerns. The College records all complaints on specific forms. Those seen were completed and had the investigation notes attached. The form specified if the complainant was satisfied with the outcome. The information related in the AQAA was that all staff received POVA training and staff confirmed this to be the case. In addition the home has a designated POVA officer and will be looking to appoint a second one since the departure of the Deputy Head of Care. In 2008 a further five staff are due to attend the POVA” training for trainers” course. The POVA officers already in post have NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 18 received specific training on the subject and updates in September 07. The organisation has specific forms for referral of such incidents. Nash College and the organisation take all allegations of abuse seriously and they are fully investigated. The CSCI receive notifications of these incidents and appropriate personnel are involved in subsequent investigation of the matter. The inspector asked all staff what they would do in the case of as staff member shouting at a student. All staff related good information on the action that they would take including the reporting of such matters. The College protects the student’s monies by its procedure of caring for it. All of the spending money is put into a joint bank account and each individual is given a bankbook that records any transactions that take place. The accounts department has banking hours when the students are supported to draw money out of the account. This gives a realistic feel to getting access to their money and is supported by the students College curriculum of managing their money. There are plans to make the money more easily accessible when the finance office is closed. Any interest that is accrued from the bank account is put into the student union account and is used for the benefit of the students. NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building provides an adequate standard of accommodation that is maintained. Some areas have benefited from refurbishment including student bedrooms and communal areas, although more work is planned and needed to maintain the College. EVIDENCE: Nash College is an adapted building spread over a large area with several sites. In parts the building in unsuitable for the level of disability that students who attend there, present with. There are proposals to relocate within the next five years therefore it is a fine balance between maintaining it to an acceptable standard whilst not over spending on a building which will eventually be vacated. The top floor is staff accommodation providing offices, staff rest areas and meeting rooms. This area is in need of refurbishment. The Principal stated that this area had already been identified for refurbishment and money allocated for it’s redevelopment. NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 20 It was evident that improvement had been made to building including communal areas. Some bedrooms were personalised and appropriate to the age of the students. Bedrooms were decorated with posters of pop stars football teams and other interests. New bed linen had been purchased with a choice of designs and three sets issued to all students. The window curtains were in the process of being addressed as some had become detached from the curtain rail and looked untidy. It would be preferable to store incontinence pads out of sight. The areas were clean and most parts generally well maintained although the amount of equipment used in the College does impact on the wear and tear to paintwork and walls. The radiator cover on the first floor corridor was damaged. A new bathroom had been installed on the fist floor, this area was very pleasant and the colour scheme had been chosen by a student. The student communal areas include recreational areas and a large ground floor canteen. NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to meet the students needs. Staff are provided with mandatory training and that which is specific to the area of work and needs of the students. Robust recruitment checks ensure staff are safe to work with the students. EVIDENCE: The College has a full multidisciplinary staff team. The staff team comprises not only nursing and care staff but also educational workers. Psychologists, physiotherapists, occupational therapists and a number of ancillary workers support them. The College employs thirteen qualified nursing staff. Within the information provided in the AQAA it stated that recruitment days had been organised October 2006 with a second one planned for the end of January 2008. Local adverts invited interested parties to attend should they want more information about the work of Nash College. Currently there are no qualified nursing staff vacancies, however there are 18.4 support worker vacancies. Agency staff are provided to deal with the shortfalls. Several of the agency staff have been in post for a long time. NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 22 The inspector met with staff throughout the day, including a Unit Manager a permanent staff member and an agency qualified nurse. The inspector asked about induction, ongoing training and support provided by the College. All staff apart from the agency nurse confirmed an induction period. The agency nurse had started two years previously and had had little in the way of induction although did confirm that on her first shift she had been assisted with medication administration. This was discussed with Principal who had implemented changes to agency staff induction and training who were working at Nash. The home provides staff with mandatory training, which is updated regularly. In addition specific training is provided including the LDAF. All staff attend LDAF within six months of employment. To date 75 staff have attended a behaviour awareness training session and 24 a conflict management session. The development officer manages training and development. Clear records of the training that each staff member receives are regularly updated. This is important as the College has a very large staff team with some staff turnover. All staff have a training needs assessment when they are first recruited and annually thereafter. Staff are provided with training suited to their identified needs. The Collage enables and supports staff to take Basic English and Maths qualifications if needed, as well as the work related training. All staff are allocated two hours a week of protected time on the rota for training purposes. New staff undergo a program of induction during which time they will spend time with the development officer discussing the program and working through the induction pack. Three staff files were examined for evidence of the recruitment checks made prior to employment. The files were stored in a locked filing cabinet, were well ordered and contained all of the required information. Evidence that Criminal Records Bureau’s and POVA first checks had been undertaken, two written references obtained, and that staff had been given copies of the code of conduct and terms and conditions of employment were all on files. All care staff are on probation for six months and the files contained probation reports as well as their applications and interview notes. Over 50 of staff have achieved NVQ qualifications. The College operates a cascading system of supervision. The Head of Care supervises the Deputy Head of Care, who supervised the Unit Managers; they supervise the Team Leaders who in turn supervises the Support Assistant’s. The supervision sessions take place 4 to 6 weekly. There is a set format for this and issues at the moment included a high level of absences due to illness and long-term sickness and staff resisting changes to practice. Team Leaders send a monthly report to the Unit Manager and any issues arising from supervision that need to be taken forward are raised in that report. New staff members have a six-month probationary period and during that time their supervisor will produce three probationary reports. If a new staff member NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 23 fails to come up to the expected standards will receive supervision every two weeks. The College has a Christian ethos although this is not a criteria to be employed there. NASH FE College DS0000070229.V352587.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent individual who is supported by the organisation manages the College. Health and safety issues are well addressed and this provides students with a safe place to live. Quality assurance measures take into account the views of students, staff and others to identify areas where improvements could be made. EVIDENCE: The Registered Manager is a qualified nurse and has a management qualification. Angela Crooks has completed the CSCI process to become the Registered Manager of the College. The organisation (Grooms- Shaftesbury) NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 25 supports the Manager in maintaining her skills and knowledge. On the day of the site visit she was attending a two day training session. The second inspector viewed the health and safety records. The standard of health and safety was very high, a program of checks and servicing was in place and most of the work was carried out during the school holidays when the College is shut to cause as little disruption as possible. A sample of health and safety records was examined and all were found to be in order. COSHH assessments are carried out and have recently been updated. The students that board at the school are protected from injury while being moved because Moving and Handling training is mandatory and the and development officer keeps clear records and ensures that all staff undertake this training and receive regular updates. The organisation conducts Regulation 26 visits and reports are available. A Quality Manager is also employed. The College conducts an annual selfassessment. A student survey is conducted on an annual basis and the results scrutinised. One recent survey highlighted issues with the food hence the menu was reviewed. Another survey identified the need to provide more opportunities to worship. Since that survey students have been supported to access places to worship. A service development plan is in place for the academic year. The College is subject to inspection from not only the CSCI but Ofstead, who make visits and may require issues to be addressed. There was discussion around the differences and sometimes difficulties of working with two statutory bodies and the different legislation. NASH FE College DS0000070229.V352587.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 X 2 3 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X NASH FE College DS0000070229.V352587.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. 1 YA20 Standard Regulation 13 Requirement The Registered Manager must ensure that all controlled drugs are fully recorded. Timescale for action 28/02/08 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 YA20 2 YA20 Refer to Standard Good Practice Recommendations The Registered Manager should review the medication administration practices in the College The Registered Manager should ensure al trained nurses are updated in medication procedures on a regular basis NASH FE College DS0000070229.V352587.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 NASH FE College DS0000070229.V352587.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. 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