Inspection on 04/05/05 for Westgate College for Deaf People and the ROAD project

This inspection was carried out on 4th May 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westgate College for Deaf People... 05/02/07

Westgate College for Deaf People... 21/12/05

Westgate College for Deaf People... 07/03/05

Westgate College for Deaf People... 07/12/04

Similar services:

89 Hastings Avenue

39 Westway

24-26 St John`s Road

David Gresham House

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

CARE HOME ADULTS 18-65 The Royal School for Deaf Children - Westgate College Royal School for Deaf Children, Westgate Victoria Road, Margate, Kent, CT9 1NB2 Lead Inspector Patrick Gough Announced 04/05/2005 at 9:00hrs 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 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 Stationary 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. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Royal School for Deaf Children - Westgate College Victoria Road, Margate, Kent, CT9 1NB Address Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01843 227561 Royal School for Deaf Children/Westgate College Mr Mark Frazer Peoples Care Home 80 Category(ies) of Sensory Impairment (80) registration, with number of places The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/03/2005 Brief Description of the Service: Westgate College is registered to provide residential accommodation for up to 80 young people and adults aged 16-65 although current service users fall within the 16-25-age range. The accommodation and facilities for the service users is provided on three separate sites, with two of the buildings located in Westgate-on-sea and three in Margate on the site of the Royal School for Deaf Children Margate. Westcliff House, the main college site, which has commanding views over the channel, has seven residential areas as well as office areas for the administration team, senior managers, some teaching space and a medical/specialist room. St. Gabriel’s, the other premises in Westgate, provides accommodation for up to 20 students. All bedrooms are single occupancy. This building also provides education facilities, including an ICT suite and a kitchen designed for the teaching catering courses. Thanet Lodge, a detached two-storey building, has ten single occupancy bedrooms and like the other remaining premises, Allen Wing 3 and 4, is located on the school site in Margate. Allen Wing 3 is a detached building with accommodation for seven students and at the time of the inspection offered single sex accommodation. Allen Wing 4, situated alongside 3 is also detached and has can accommodate four students Local shops other facilities and The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted over a three-day period by two inspectors. A pre-inspection questionnaire was completed by the Manager and other material, including a self-assessment tool was submitted prior to the inspection. Evidence was gathered from small group interviews involving 28 students and an individual interview with a student. Discussions and interviews were conducted with individuals and groups of staff, representative of the various College sites. Mealtimes were observed and practice was evidenced during the extended curriculum period, 4-7pm. A sample of student files as well as some personnel records were examined. Various other records were seen, including health and safety, staff meetings, staff supervision and student behaviour-related records. The inspectors found that the management, staff and students were cooperative, open and confident in their responses and engaged fully in the inspection process when required. What the service does well: The College provides all students with an excellent variety of activities and occupation and has strong links with the local community. It develops students into becoming independent and supports them making personal relationships as young adults. There are good safeguarding policies and processes, which are managed well and the students confirmed that they feel safe. The residential provision is managed effectively and there is good leadership and support provided by the Manager. There are excellent vocational and life skills programmes being implemented, enabling students to achieve varying degrees of independence. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 6 Very good relationships exist between the care staff and the students. What has improved since the last inspection? What they could do better: The student handbook could be put into different forms for students with special needs and the parent’s handbook could have the Commission’s address and telephone number in so that they can contact us. Care risk assessments could be audited to make sure that any actions highlighted are followed up. The confidentiality policy, for staff to follow, needs to be agreed by the governing body as it is still in draft form. Students having meals in the main College to be offered an alternative menu to meet their needs. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 7 The College to train more staff in the giving of emergency rectal medication on Johnson Wing, so that they can administer the medication in cases of emergency and not have to rely on staff from other units. The College must have a maintenance plan to keep the students’ communal facilities and accommodation in a good state of repair and ensure it is pleasant to live in at all times. In order that staffing levels are kept at an acceptable level so that students are supervised and supported at all times, the recruitment policy must be updated. All policies and procedures should be reviewed regularly and amended as necessary. The Manager must be given an updated job description and regular formal supervision and support in order that he has the necessary guidance to carry out his duties. The response given, by all senior staff, particularly if ‘on call’, when called upon for assistance, must be consistent. The quality of care practice must be checked and monitored regularly to ensure that the students are being well looked after and that the staff have the resources to do their job. 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 Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 The College has policies and procedures for prospective residents’ admission and they are provided with written information. A recommendation was given for the student handbook to be available in other forms e.g. widget symbols or video for those students with special needs and the parents handbook to have our details in, so that they can contact us. Students’ needs are fully assessed and they are informed of their rights and the College expectations. EVIDENCE: The Manager has confirmed that the College prospectus, statement of purpose and student handbook is given to students and parents so that they can make a choice about moving there. Students told the inspector that they had been given a copy of the student handbook and some said that they would prefer it in widget or video form for easier understanding. They said that they knew about their rights and the rules of the College. Students have a full educational and care needs assessment before admission, and placement plans are developed from this and were seen on student files. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 10 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 standard(s) 6,7,9,10 Students’ care plans and risk assessments contain assessed needs to ensure individual choices are met and their independence is promoted. A recommendation was given for care risk assessments to be audited by the staff to ensure that they are in place and actions identified are being followed through. Students make decisions about their lives from good support from staff and they are consulted about any changes. The staff policy on student confidentiality needs to be agreed by the governing body and a recommendation is given for this to be completed. EVIDENCE: Student’s needs are assessed by many different professionals at the College to ensure that all their needs were being met. This was seen in the care plans, occupational therapy, physiotherapy and speech therapy assessments and the educational input from the College. Students attend annual reviews and are consulted about all aspects of their care through the key worker system in the College. The way students are The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 11 consulted was seen in the records of house meetings, student questionnaires, the food committee and the student council. Staff, which were interviewed, demonstrated their understanding of individual student needs and records seen showed them being provided. Students are encouraged to be independent and follow life skills and independence programmes which include them doing work experience, going out on their own, cooking, shopping and budgeting. It was seen on one students file that he was assessed as having a particular care need and no risk assessment had been completed, although records showed his needs were being met. Information was being kept confidential on files and staff showed an understanding of what information needed to be disclosed to keep students safe. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12,13,15,16,17 All students use a wide variety of community facilities, which give them the opportunity for personal development and to take part in appropriate activities. Staff support them in having contact with relatives and friends and to build personal relationships. Students’ rights are respected by staff through the care being provided in the College. Students’ meals are sociable occasions. A recommendation was given for students having meals in the College to have an appropriate menu offered which will meet their needs. EVIDENCE: Discussions with young people and staff and daily records and placement plans seen, showed that students are helped to be independent and use all the College and community facilities on offer. This includes attending further education, work experience, joining clubs and using local community facilities, The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 13 despite how complex the students assessed needs are. This is promoted through the life skills programme from the College. Students are given excellent support and advice in making personal relationships and keeping in contact with family and friends. Staff follow policies which ensure that students rights are respected in their daily routines and students have keys to their rooms and were seen being treated with dignity and respect. Students’ cultural and religious needs are respected and provided for in their placement plans. It was noted that students having meals on the College premises have the same menu as the children at the Royal School For the Deaf and students said that it was not appropriate for their age group and growth needs. They asked that the menu be changed for them. Students living in other houses said that there had been an improvement in the selection and choice of food and that they had been given a food survey to complete and there was a food committee for them to bring up areas for change. The inspectors joined students for meals. They had a choice of hot and cold meals of large portions and fresh fruits and yoghurts were available. Students living in St. Gabriels said there was a problem with not having enough food for supper because day students were using it. This was brought to the manager’s attention by the inspector and he agreed to follow this up with the catering manager. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 14 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 standard(s) 18,19,20 The health needs of students were being well met with evidence of the College working closely with other professionals. Personal support is offered to meet individual student needs. There are systems in place for the safe handling of medicines and the manager and health centre staff monitor these. A recommendation is given for more staff to be trained in giving emergency rectal medication so as not to have to rely on staff coming from other units. EVIDENCE: Students’ health needs were seen recorded in care plans and records showed key workers were providing personal care and support. This includes help with personal hygiene, accompanying residents on health appointments and supporting them in care reviews. Interviews with the occupational and physiotherapist for the College showed that they work closely with care staff in order to meet the students individual needs. There are healthcare and personal care policies, which staff follow to ensure residents health needs are met. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 15 There was an absence of separate health care plans on files and the inspectors were informed that they are held in the medical centre. It was advised that copies could be kept on student files in order that care staff have access to them if needed, although files did have basic health information on them. Students’ medication is reviewed. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 16 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 standard(s) 22,23 The College has a complaints format and process in place, which enables the students to have access to support and assistance with concerns and serious issues. The College has promoted good safeguarding practices through its over arching protection policies and good staff/student relationships, enabling the students to express concerns and live in a safe environment. EVIDENCE: No complaints were registered in the complaints book since the previous inspection. However in discussion with some of the students the inspector was informed of a number of issues relating to acknowledgment of student privacy and staff/student relationships that should have been raised as a complaint and dealt with accordingly. A new format has been developed to include a section to allow for the student’s feedback on the outcome of actions taken to address the complaint. The students, through face-to-face discussion and in their survey responses, indicated that they know how register a complaint and that they are taken seriously. Of previous complaints made, there was written evidence of the action taken and the conclusions reached. The latter two complaints, which were registered, refer to bullying and teasing and in each case a letter was sent to the student who made the complaint informing them of the outcome. The response The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 17 regarding the bullying issue written on 5/3/2005 does not however indicate whether it was resolved to the satisfaction of the complainant A response to a complaint about teasing, 26/1/2005, informs the student of their right to complain to the Commission if dissatisfied with the outcome. The Manager has drafted new policies on Child Protection and Adult Protection to provide up-to-date guidance for the staff. These policies have not yet been ratified by the Governing Body. The records relating to protection of students indicate the number of issues raised and the number of referrals and consultations sought. All the staff, which were interviewed, were able to confidently describe how they would respond to a disclosure and the process of referral. The students indicated that they felt safe in the care of the staff and those who were capable of independent mobility stated that they were informed of self-protection procedures. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 18 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 standard(s) 24,26,27 The premises were clean and safe but a planned maintenance programme would manage decoration needs more adequately and provide the students with better quality surroundings. The College needs to improve the quality of the monitoring of students accommodation so that students have a safe and comfortable bedroom accommodation. The communal bathroom and toilet facilities are accessible, private and clean thus ensuring privacy and reducing the risk of infection. EVIDENCE: The inspection findings relating to the College environment, particularly student accommodation, takes into consideration proposed plans to build new accommodation on the School site. Given that it will improve considerably the bedroom and communal facilities for the students, the inspectors were focussed mainly on aspects, which may compromise student’s safety and should be addressed more urgently. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 19 The Westcliff premises, though not ideally suited for its purpose, have been maintained sufficiently to maintain the students’ safety and comfort. Some of the decoration is bland and would benefit from more colour. The communal area in Johnson Wing, particularly the sensory facility has been improved, with more consideration for student’s privacy. The other premises, whilst off the main site, are within easy reach. Allen Wing 3/4 has seen some improvement but would still benefit from a planned schedule of redecoration. The rooms are spacious and there is adequate communal space for socialisation and activities. The furniture in communal area is adequate in quantity, however some of it is shabby and needs replacing. Thanet Lodge consists of separate group living facilities enabling the students to live more independently with staff support. The premises, on the whole, were clean, safe and comfortable and responses from the students confirmed that they were satisfied with the quality of accommodation. There appears to be a reactive response to maintenance and renewal of the fabric of the building and whilst this is done within a reasonable timescale, with priority given to safety issues, a more planned approach through an annual maintenance programme would communicate to all staff, plans for the following year. Most areas are wheelchair accessible and where this is not possible there is no adverse impact on wheelchair users in respect of their rights or individual needs. All students are accommodated in single bedrooms, some of which are very spacious. Few bedrooms were equipped with comfortable chairs although the Manager stated that they could be provided on request. Some of the carpets need to be replaced, however they were clean and safe. The students indicated that they were satisfied with their accommodation and valued their personal space They are allowed and encouraged to personalise their rooms and whilst some contained just the basic furniture others had lots of posters and personal effects. One student’s bedroom had an adjoining small, fully equipped kitchen, which although risk assessed remained a high risk, given the proposed actions had not been implemented. The Manager was informed that the student’s bed was inappropriate and some electrical wires could have posed a danger. Another student’s bedroom had no wardrobe for hanging clothes. Some bedrooms have en-suite facilities and all students have easy access to bathrooms and toilets. The bathrooms were clean and well equipped. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,36 Staff shortages, through high levels of sickness and the necessity to supervise the practice of some staff, has reduced the capacity of the staff team to deliver an efficient service to the students. The lack of an up to date recruitment policy and process contributes to staffing difficulties and the level of supervision and support given to students by appropriately checked staff. Whilst the level of support given by the Manager is rated as good, there are inconsistencies in the nature of assistance given to staff by other senior personnel thereby increasing the risk to staff and students. EVIDENCE: The staff/student ratio is determined by a thorough needs assessment conducted by the College based on the Learning and Skills Council formulae. The Manager also uses the Residential Care Forum guidance to calculate the personal needs element of the student’s care. The staff who contributed to the inspection findings indicated that there is shortage of staff, which at particular times, for instance in the mornings, adversely affects the care and the supervision that the students receive. The The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 21 difficulty is exacerbated by the need for more experienced staff to supervise the practice of staff, which have not satisfactorily completed the recruitment process. A recent restructuring programme has had an adverse effect on staff morale. The Manager confirmed that there is a high incidence of staff absence through sickness and other staff stated that some teams are depleted through having to provide cover in these instances. Some students commented on the lack of staff to accompany them on off-site activities and stated that occasionally they were unable to participate because there are insufficient staff. Regular staff meetings are held and records of proceedings are kept. There are some ‘standing agenda items’, such as policies and procedures and student issues. The content of the meetings suggest that practice issues are discussed. The recruitment policy and process has not been reviewed and amended to include more recent guidance. Some personnel files were sampled and they revealed a number of inconsistencies in the content of the file and the way information is recorded. There was no evidence that applications for a CRB check had been submitted other than a tick on a checklist. The checklist does not refer specifically to a CRB check. The staff confirmed that there is good support given by the Manager, both through formal and informal supervision. The supervision format and records of the process suggest that practice issues, student’s progress and training needs are discussed. The staff were not so praiseworthy of the support offered by some of the senior on-call personnel, indicating that there has been an inadequate response on occasions. The Manager has not received formal supervision. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,41,42 The Manager requires a clear job description defining his role and the necessary supervision and support in order that he can more effectively manage and support his staff. The residential provision within the College is well managed, enabling the staff to develop their practice with the students. There are no formal quality assurance systems operating on a regular timescale monitoring the management of the care provision and therefore no effective method of measuring the quality of the service to the students. The policies and procedures governing the practice have not been reviewed and amended sufficiently to provide up-to-date guidance for the managers and staff. There are good vocational and life skills programmes in place enabling the students to access and develop the skills necessary to achieve some level of independence. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 23 Inadequate implementation of safe working practices could pose a risk to the safety of the staff and students. EVIDENCE: The Manager has not been provided with a job description, which clearly defines his role and outlines his responsibilities. As earlier indicated, the Manager does not receive formal supervision and therefore given that there is no formal appraisal system in place for care staff, there is no formal setting to agree the training and professional development needs of the Manager. There is a clear sense of direction and leadership from the Manager, and Team Leaders, when discussing systems and practice, were complimentary of the management style. There was evidence that the Manager is well informed and possesses a good knowledge of daily practice and how the service is being provided. There is, however, no formal method of measuring the quality of the service on a regular basis. The fact that the staff and students are operating on different sites increases the importance of good monitoring system, which may have to be conducted by more than one senior practitioner. The College has recently completed, at the request of the Learning and Skills Council, an assessment of its overall provision in order to satisfy the funding body that it provides a quality service for each student. There is also no evidence of visits by the Registered Individual to inspect the premises and measure the quality and standard of care provided at the College. The College has many of the policies and procedures in place, as required, however most are outdated and have not been reviewed or amended to incorporate new guidance or legislation. Some new policies written in accordance with the recommendation at the previous inspection are still in draft form awaiting ratification by the governing body. The students have access to those policies pertinent to their care and safety and the staff have been supplied with copies of draft guidance on confidentiality and the safeguarding of students. The staff were conversant with the content in important documentation relevant to the care of the students. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 24 Students who have the ability to participate in learning programmes are encouraged to engage fully in contributing to records of their achievement. Records were kept in a secure place. There were inconsistencies in the way files were organised and how student’s progress was monitored. The Vocational and Independent Living Skills programmes are excellent in their content. It was not evident, however, how the students had achieved the progress indicated by the ticked boxes in the checklist. An immediate requirement was issued to implement fire safety practices. There were no fire safety records documenting regular fire drill practice or regular visual checks on fire equipment on the premises. The responsibility to do so has not been delegated and one member of staff, with no clear job description, stated that she conducted visual checks even though it was not her defined role to do so. Some risk assessments have been conducted but there was evidence that it is not sufficiently rigorous. The inspectors noted that where one assessment had been completed, the actions had not been implemented. In another instance, where a risk relating to poor road awareness was identified there was no formal risk assessment. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 1 3 x x x Standard No 11 12 13 14 15 16 17 x 4 4 x 4 3 3 Standard No 31 32 33 34 35 36 Score x x 3 2 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Royal School for Deaf Children - Westgate College Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 4 2 2 3 1 x H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 26 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 24 Regulation 23 Requirement The College shall ensure that a maintenance plan is produced so that routine maintenance can be addressed within a reasonable timescale and more major refurbishment is prioritised. The College shall provide appropriate bedding for all students. Arrangements shall be made to provide students with bedroom accommodation which is free from hazards. The College shall provide appropriate storage facilities for students clothing. The College shall review and amend the recruitment policy to ensure that it is up to date and complies with latest guidance. The Responsible Individual shall conduct unannounced visits, on a monthly basis, in order to monitor the quality of the provision and provide a copy of the visit report to the Commission. The Registered person shall establish and maintain a system for monitoring and reviewing the quality of care at the College, on H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Timescale for action 1/10/2005 2. 3. 26 26 16 13 1/09/2005 1/09/2005 4. 5. 26 34 23 19 1/09/2005 1/09/2005 6. 39 26 1/09/2005 7. 39 24 1/09/2005 The Royal School for Deaf Children - Westgate College Version 1.40 Page 27 8. 42 23 9. 42 23 a monthly timescale, and submit summary quarterly reports to the Commission. The College shall make adequate arrangements for conducting fire drills, checking fire equipment and the maintenance of such equipment at the appropriate intervals. The College shall ensure that proposed actions resulting from risk assessments relating to fire hazards are addressed. 1/09/2005 1/09/2005 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. i Refer to Standard Good Practice Recommendations The student handbook to be presented in other forms e.g. widget or video, for students with special needs. The parent handbook should include the Commission details so that the parents can contact the Commission if necessary. Care risk assessments to be audited to ensure that they are in place and actions following identified risks are followed through. The confidentiality policy should be ratified by the Governing Body. Students having meals in the main College building should be offered menus that meet their needs. More staff on Johnson Wing should receive training on medication administration. The College should continue to review its staffing levels in response to available guidance, staff expectations and other determining factors, such as staff absence. The College should establish an annual appraisal system for all staff. The Manager should be provided with regular formal supervision and a training plan agreed to ensure that training needs, commensurate with the role, are addressed. The Manager should be provided with a job description, which clearly defines his role and outlines his responsibilities. H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 28 2. 3. 4. 5. 6. 7. 8. 9 10 17 20 33 36 36 9. 37 The Royal School for Deaf Children - Westgate College 10. 40 11. 41 All policies and procedures relevant to the management of the provision and the implementation of practice within the College should be reviewed on a regular timescale and amended accordingly. Records of students achievements should clearly evidence how targets have been met. The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent TN23 1HU 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 The Royal School for Deaf Children - Westgate College H05 H56 S34680 Westgate College V227310 04072005 Stage 4.doc Version 1.40 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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