Inspection on 08/05/07 for National Star College

This inspection was carried out on 8th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

National Star College 23/06/09

National Star College 14/03/06

National Star College 14/11/05

National Star College 03/03/05

National Star College 05/10/04

National Star College 26/02/04

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

CARE HOME ADULTS 18-65 National Star College Ullenwood Manor Ullenwood Cheltenham Glos GL53 9QU Lead Inspector Mrs Eleanor Fox Key Announced Inspection 8th May 2007 09:30 National Star College DS0000016642.V333204.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 National Star College DS0000016642.V333204.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. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service National Star College Address Ullenwood Manor Ullenwood Cheltenham Glos GL53 9QU 01242 527631 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) National Star College Mrs Christine Harber Care Home 88 Category(ies) of Physical disability (88) registration, with number of places National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14/03/06 Brief Description of the Service: The National Star College is a College of Further Education, providing residential accommodation for students with physical disabilities or acquired brain injuries. The main campus is based at Ullenwood Manor, situated in beautiful grounds, above Cheltenham town centre, and approximately five miles from the city of Gloucester. The campus is made up of various education buildings, a large sports centre with swimming pool, administrative offices and accommodation areas; all are accessible to wheelchair users. A mobility maze has been constructed to assist students to learn to negotiate difficult surfaces. The residential provision at Ullenwood comprises a number of accommodation areas; each managed to suit differing service users’ needs. These are: Wilson Court, which is home to 45 students in single bedrooms on two floors, accessed by a shaft lift. The purpose-built unit has assisted toilets, bath and shower facilities. The students also have a large lounge with kitchen facilities on the first floor. Cotswold, which opened 6 years ago, has 12 en-suite single rooms for students who have a high level of need. This accommodation includes a dining and living room, with a purpose built kitchen. Cotswold also has additional therapy rooms, a relaxation unit, and a large lounge/dining area. The Shortwood complex is made up of the Farmhouse, which houses 19 students in single and twin rooms. There is a kitchen and communal lounge area. A garden flat at the side of the house provides shared accommodation, plus cooking and bathroom facilities for two students. This accommodation area is scheduled to be totally upgraded and refurbished during the summer vacation. An extension has been added to the bungalow formerly known as Moose; this accommodation is now called Malvern and provides an additional 5 well equipped single en-suite rooms, as well as a new lounge/diner with kitchen facilities. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 5 Finally a brand new unit, known as Cleeve, was commissioned in the new year. This area provides single en-suite bedrooms plus dining and lounge facilities for ten students. The medical base for the campus is in the same building as Cotswold: it has a dedicated sick room and consultation rooms. Students have access to a variety of transport, including a coach, mini-buses and taxi. All are accessible to students who use wheelchairs. Subject to planning permission a further extensive building programme is planned for the property in the coming months to further enhance the facilities offered. The provider supplies information about the service, including the most recent CSCI report, to students and their advocates on request. The current scale of charges is maintained within the Learning and Skills Council matrix. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to The National Star College and takes into account the views and experiences of the young people using the service. One inspector undertook this unannounced inspection over two days in May 2007. During the visit, she chose the care of nine of the students for particular scrutiny. She met each of them, where possible speaking to these young people for a short while in privacy, read all their relevant records and visited their bedrooms. In some cases she was also able to observe their participation in a number of activities. The inspector read selected personnel and recruitment records and examined the training and complaints files. She also walked around the property, visiting each of the accommodation units, the health centre, kitchen facilities, the communal areas and the administration offices. She had the opportunity to observe the service of meals during her inspection. She also examined the opportunities for students to exercise choice and to maintain social contacts. The inspector spoke with some of the staff who were on duty on these days, checking their understanding of some of the College’s policies and procedures and discussing their experiences within the establishment. These included the nursing staff who explained the processes for the administration of medications and provision of any required medical interventions. Finally, she had the opportunity to talk to the Registered Manager and to other senior staff, particularly in relation to general management issues and future plans for the College. All were open and most cooperative in providing information as requested. Prior to the inspection, CSCI surveys were distributed to students living at the College and to staff working there. Thirty-two completed surveys were returned from members of staff; thirty-four were returned from students. Many of their opinions are reflected in the content of this report. What the service does well: National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 7 Each prospective student undergoes a most comprehensive assessment prior to being accepted for a place at the National Star College. Each person is also given the opportunity to attend a short course, known as ‘Stars of the future’ to gain an insight into life at the College. Clearly detailed plans of care relating to all aspects of their lives are developed for each person. Any restrictions to independent living are agreed on the basis of appropriate risk assessments. Students receive sensitive support and encouragement to lead as full and independent a life style as possible throughout their stay at the College. They are given the opportunity to take part in a wide variety of activities if they wish and are provided with tuition and support to develop personal, social and educational skills. A good standard and variety of food is offered which, on the whole, suits the tastes and preferences of the students attending the College. In some cases, they are also facilitated to prepare and cook their own meals when they wish. The management of health care needs, including medication administration is addressed well; students are given support to take responsibility for directing their own care as much as possible. Any complaints or concerns are addressed promptly and, if required, full investigations are undertaken and remedial action taken. Employees have the opportunity to attend training appropriate to their work, which includes a good focus on the national vocational training and protection of vulnerable adults. The College has the benefit of strong leadership and committed focussed management. Health and safety matters are also addressed well. There is a commendable focus on quality improvement at the College. The staff are to be congratulated for providing a positive and friendly environment for the students during their stay at the College. Responses to the survey were overwhelming in their appreciation of the kindness and understanding of the employees supporting and caring for the young people living there. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? 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. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Students are only accepted at the College once a thorough assessment of all their needs has been undertaken. Young people are also given ample opportunity to experience life at the College before a final decision about admission is agreed. EVIDENCE: Each prospective student is thoroughly assessed prior to being offered a place at the College. Two young people accompanied by their parents were undertaking assessment during the inspection. The multidisciplinary assessment involves input from the behavioural psychologist, nursing staff, occupational therapist, physiotherapist, residential manager, speech and language therapist, and tutors. Relevant information is also sought from schools, medical personnel and other specialists before the young person is accepted at the College. The initial assessment documentation is maintained for reference and further development when the student eventually moves in to his or her allocated residence. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 11 Not only do the prospective students come for a visit to the College, they are also invited to attend a ‘Stars of the Future’ course, arranged during the Easter holidays, to gain experience of College life prior to their admission. One person described how “reassuring” this had been, particularly as he had been most apprehensive about leaving his family for the first time. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are comprehensive care planning systems in place, including risk assessments, which give detailed information to ensure that students’ health, personal and social needs are met. Students are supported to have autonomy over their individual life styles. EVIDENCE: Clearly detailed plans are developed and recorded during the first few weeks of the student’s stay at the College. These address all areas of the young person’s care and life style needs and are completed with the full input of the person concerned. Where possible the student signs the completed documentation. Reviews are normally undertaken as appropriate, but usually at least twice a term following discussions with the student, key worker and senior member of staff. In one instance a further review was now required to accurately reflect the student’s current situation. This was being addressed. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 13 Some of this information is also recorded electronically, ensuring improved communications between other appropriate disciplines on the College campus. It is recommended that consideration should be given to extending the data stored electronically and reducing the amount of handwritten documentation still maintained in each area. During conversations with the students, inspection of the recorded information in the plans and observation of a Students Union Meeting, it was very evident that the young people are supported and encouraged to make decisions and choices about all aspects of their daily lives. Those with communication difficulties are provided with assistance from staff, peers and communication equipment. Students are also supported to take responsibility for their own monies. Records of any required training and support are clearly recorded. Any restrictions imposed on the student are only undertaken following comprehensive risk assessment procedures involving multidisciplinary input and including all parties concerned. Comprehensive risk assessments are completed for each student; where particular issues are identified further enhanced risk assessment are produced. These give very detailed instructions to all persons responsible for providing any form of support or care. In the examples seen on this occasion, details are normally reviewed and amended appropriately. There are written procedures in place to address any unexplained absences. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Students are facilitated to live as full and independent a life as possible. Good opportunities are provided for varied and stimulating activities to occupy the students and thus improve their quality of life. Students are supported to maintain any links they wish with family, friends and the local community, thus adding interest to their lives through social contact. An excellent standard and variety of nutritious food is provided for students and staff living and working on the Campus. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 15 EVIDENCE: As soon as the student commences at the College, he or she works with staff to prepare and develop personal development goals. These are clearly recorded, as is the student’s progress towards achieving their personal targets. Two of the students chosen as part of the case tracking processes were observed working towards these goals; one was undertaking a cooking exercise; the other was planning a shopping trip. Throughout the student’s time at the College, the main focus is on the education and training for their future life. One person described in detail what he was planning to do when he left the College in the summer. He now felt confident to live independently and to undertake employment locally. The students participate in a wide variety of college educational activities; facilities and equipment are provided to suit their differing needs. The students are facilitated to participate in local community life as much as they wish and are able. During conversation they described their trips to local clubs, sports centres and pubs; many also enjoy shopping in one of the local town centres. They use college transport or alternative methods with staff support, if appropriate. Students may take part in an extremely wide variety of college leisure activities if they wish. These are arranged throughout the week and include sports, creative pursuits, drama, and other special interest groups. They also have access to the college bars and communal meeting areas. Some prefer the privacy of their own accommodation area where they may watch television, listen to music or enjoy alternative pursuits of their own choice. Students are supported to develop friendships and relationships as they wish. They maintain contact with family and friends, usually with the use of mobile telephones. Students also have the opportunity to visit each other in their different accommodation buildings. Sensitive support is given to those young people experiencing homesickness, particularly during their first term at the College. One person described the care he was given during this difficult period. Students living in the various accommodation units meet and agree to live within the self regulated Student House Guidelines. One person described to the inspector how these had been decided at the beginning of the College year. They have the opportunity to keep their bedrooms secure as they wish. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 16 Throughout the inspection members of staff were seen respecting the students’ privacy and dignity both in their manner and their approach to each person. One student wrote, “I can always talk to my key worker because she is ‘fab’. The staff listen to your issues and problems and then put them right.” Students are provided with a commendable choice of food to suit their differing needs and wishes. Menus are devised following regular consultation with the students themselves; the head chef was due to attend a student union meeting shortly. Where possible, healthy eating options are promoted and encouraged. Meals for students with particular dietary needs, medical or ethnic, are prepared as required. Conversation with the catering staff showed that efforts are made to find particular favourites to tempt those with poor appetites. ‘Themed meals’ are prepared for special occasions such as Valentines Day, Bonfire Night, and national Saints Days etcetera. The students also have access to their own cooking facilities and sometimes prefer to eat ‘take away’ meals for a change. Students were observed eating their food in a relaxed and informal manner. Those requiring assistance were helped in a friendly but sensitive fashion. The kitchen was clean and well organised. The National Star College has recently been given ‘5 Stars’ ‘Scores on the Doors Award’ by Cotswold Council, a commendable achievement. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Students’ medical care needs, including medication administration, are addressed appropriately, ensuring that they receive the healthcare support they require. EVIDENCE: A team of nurses are on duty on the College campus throughout the day and night to provide trained nursing care to the students, as required. From the documentation seen on this visit, it was evident that clear records are maintained of any specific care required and provided. All identified needs and risks are recorded. Students confirmed that they are involved in any decisions about the care they receive; the completion of consent documentation further confirmed this. The students have the benefit of additional specialist support on site from occupational therapists, physiotherapists, and speech and language therapists Mechanical aids and hoists are provided, maintained and reviewed as necessary to assist the students to live as independently as possible and to assist staff when care procedures are undertaken. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 18 Nursing staff have close contact with the students, checking and maintaining records on their general health and well being on a daily basis. Students are supported to manage their own health needs including accessing medical care, dental care, chiropody and other specialist assistance as needed. There was recorded evidence that advice is sought from the tissue viability nurse when required; the nurses have just completed some additional training on wound care. The staff also receive advice and support on the care of students with gastrostomies from the hospital dietetic department. A local General Practitioner provides a surgery on site, which the students may access in private, when they wish. Information on general health issues is readily available from the specialists in the College or in pamphlet form. Students are also supported to take responsibility for their own medication administration as far as is possible; this is done on the basis of a documented risk assessment process, which is kept under regular review, and is normally introduced on a phased basis. Medications are ordered, stored and administered correctly. The CSCI pharmacist will visit the College later in the year to assess the current systems in place. Selected non-nursing staff have completed formal medication administration training to ensure that students are fully supported when they are on trips away from the college premises. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints system enables students and their families to feel assured that their views would be listened to and acted upon. Students are offered a good level of protection against abuse. EVIDENCE: Information on how to raise a concern or to make a complaint is provided to students and their families in literature about the College The students who responded to the survey and who spoke to the inspector confirmed that they were aware of the processes; most students said that they would refer any worries or concerns to their key workers Observation of the ‘Complaints File’ showed that the formal complaints about the College received in recent months had been addressed promptly and appropriately; full investigations had been undertaken as required. The protracted investigation into a complaint received by the Commission for Social Inspection relating to specific care issues of a named student has now been completed. Requirements for improvement have been fully addressed by the College. The number and content of concerns and complaints is closely monitored by the National Star College. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 20 The College provided documentary evidence to show that staff receive comprehensive training on abuse issues; this was further confirmed by members of staff who were questioned on the subject. POVA (Protection of Vulnerable Adults) Alerter training is provided to all grades of staff and updated every three years. The College has developed policies to address all forms of abuse. These are readily available for members of staff to read. Whistle blowing procedures are also included in this documentation. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of students are provided with a good standard of clean comfortable accommodation. However, some is in need of urgent improvement. EVIDENCE: All the residential accommodation throughout the campus was visited on this occasion. The bedrooms of those students selected for case tracking were also seen. Most of the accommodation is of a reasonable standard and well designed to meet the needs of the young people living there. Currently the College is subject to a major programme of refurbishment and upgrading; some areas have already been completed. Since the last inspection a new accommodation block for ten people, known as Cleeve, has been commissioned. This is a bright, extremely well equipped unit, which is already very popular with the students. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 22 The Shortwood block, however, is now very shabby with seriously damaged plasterwork and tiles missing from the walls in one of the bathrooms. Although this area is scheduled for a full upgrade during the summer holidays, arrangements must be made in the interim to replace the missing tiles so that they do not pose a risk to students using the facility. The remaining accommodation units are in reasonable condition. All areas visited on this occasion appeared clean and were certainly free from any offensive odours. Laundry facilities are provided throughout the campus and it was observed that ‘control of infection’ protocols were being addressed. In the few instances where hand washbasins are not provided, ‘hand wash gels’ have been installed for use. It should be noted that these methods are not effective for all infections and that full hand washing should be undertaken as the preferred measure. Clinical waste is addressed appropriately. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care is provided by a stable care team, which is subject to robust recruitment processes, regular supervision and has access to very good training opportunities, ensuring that the students are fully protected. EVIDENCE: During conversation with the inspector and in the completed questionnaires students described the staff as, “truly great”, “they are very kind to me”, and, “they couldn’t be better – they always listen to what I am trying to tell them.” All staff are inducted to their posts and work under supervision until they feel confident and are deemed safe to work alone. Over 65 of the staff already hold a NVQ (National Vocational Qualification), Level 2 or above, and additional staff are now undertaking this course. Personnel files relating to all the members of staff employed since the last inspection were read in detail on this visit. Each person had completed an National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 24 application form providing a full employment history. Medical details were checked. POVA (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) screening had been completed. Two written references were provided for each applicant. There was also documented evidence that each person had been inducted to his or her respective post. Staff have access to a commendable amount of varied training appropriate to their respective roles. This includes attendance at mandatory annual training; records of which are maintained and monitored. The College is currently introducing ‘Equality and Diversity’ training for all staff. They have also recently been accredited to deliver ‘Safer Handling of Medications’ training. Recorded evidence was provided in each accommodation unit to show that staff are regularly supervised and their performance is also formally appraised annually. Care workers confirmed to the inspector and in the in their completed surveys that they feel well supported by the senior staff. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The effective implementation of the documented policies and procedures ensures that the National Star College is well managed and the students’ rights upheld. There is also evident commitment to improve the services for the benefit of the students living there. EVIDENCE: The Registered Manager of the College is an experienced trained nurse who holds a certificate in Health Service Management. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 26 There are clear lines of responsibility in the senior management team, which appears to operate as a cohesive effective group. Staff surveys indicate that the managers are well respected at the College. Excellent quality improvement processes are in place at the College. Every year self-assessment and quality improvement processes are undertaken. Key strengths and areas for improvement are identified. Action plans are then developed to resolve any issues within agreed time scales. The previous year’s published report was provided to the inspector. Any complaints, accidents or adverse incidents are all monitored and audited centrally. The College holds the Investors in People and Investor in Students Careers Awards. Records were provided to show that statutory maintenance/inspection of equipment and services is arranged in a timely fashion. Where faults are identified, they are rectified as necessary. Fire prevention management and training of staff appears to be addressed extremely well. Risk assessments are recorded appropriately. The building was safe and secure throughout. Staff attend mandatory training on health and safety issues, as required. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 4 3 x 4 3 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 2 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 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 x 3 x LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 4 4 x x 3 x National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 28 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 Standard YA24 Regulation 23(2)(b) Requirement The missing tiles in the Shortwood bathroom must be replaced Timescale for action 30/06/07 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 Refer to Standard OP6 YA6 YA30 Good Practice Recommendations Consideration should be given to extending the data stored electronically and reducing the amount of handwritten documentation still maintained in each area. Consideration should be given to installing full hand washing facilities in all laundry areas. National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 National Star College DS0000016642.V333204.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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