Inspection on 12/11/08 for The Stan Bell Centre

This inspection was carried out on 12th November 2008.

CSCI found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOME ADULTS 18-65 The Stan Bell Centre 74, William Street Loughborough Leicestershire LE11 3BZ Lead Inspector Ruth Wood Unannounced Inspection 12th November 2008 12:00 The Stan Bell Centre DS0000066472.V373338.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 The Stan Bell Centre DS0000066472.V373338.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. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Stan Bell Centre Address 74, William Street Loughborough Leicestershire LE11 3BZ 01509 631300 0207 3912195 lbartlett@rnibcollege.ac.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal National Institute of The Blind Miss Linda Bartlett Care Home 20 Category(ies) of Sensory impairment (20) registration, with number of places The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2006 Brief Description of the Service: The Stan Bell Centre, Provides accommodation and varying degrees of care and support for students attending the RNIB college, Loughborough. Until recently the facility was inspected as a Further Education College, however it was registered as a Care Home in March 2006. The college does not provide long-term care, but rather individual care and support to enable students to access courses. Some students will have individual support programmes, which may involve one to one staffing to enable them to access the college facilities and experience a group living environment in a college setting. The average stay in the Stan Bell Centre is from one to three years. The Stan Bell Centre consists of fifty-nine single en-suite bedrooms, divided into five flats of ten and one of nine. One flat is exclusively for the use of older learners (over 25). The service is registered for twenty people and these people live throughout the home in the remaining five flats. Each flat has its own kitchen/dining area and there are a variety of communal lounges that can be accessed by all the students. The registered facility at the Stan Bell Centre currently accommodates students between 16 and 25 years of age although it is registered to provide a service for people up to 65 years of age. An electronic key system ensures that learners can only access their own room and flat and certain communal areas. Most students take their main meals at the restaurant in the main college block. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This inspection visit took place on a weekday between 12noon and 6pm. During the visit we spoke with the registered manager and two other senior staff members focussing on the arrangements for assessment, admission and care planning. As part of this process we examined the files relating to five people and discussed how all aspects of their needs were met. We spoke to two of these people directly. We examined the training and recruitment records for four staff and spoke directly with one staff member about their experiences of recruitment, induction and training. We made a tour of all communal areas of the building and, with their permission, saw two people’s study bedrooms. The administration and storage of medication was also examined. In addition to this inspection visit, information from the following sources has informed this report. • The Annual Quality Assurance Assessment completed by the service, a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. • Four responses to the Commission’s survey to people living at the service. This asks questions about people’s impression of the support they receive and whether they have the opporutnity to make choices and take decisions about their lives. • Three responses to the Commission’s staff survey. This asks questions about the recruitment process, supervision and training. What the service does well: People who live at Stan Bell are very enthusiastic about the support they receive from the staff team and the relationship that they have with them: “The care staff are brilliant” “There is always someone to talk to.” “We get all the help we need”. People are very well supported to improve their independent living skills and they agree targets with their key workers at the beginning of each term in such areas as doing laundry and cooking. People said that they had opportunities to make decisions about their lives and to do the kinds of things The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 6 that they wanted to do. This includes a variety of extra-curricular activities such as music and drama, art and craft and athletics and yoga. Good facilities are also in place to support people in their studies; the Centre has a study room equipped with personal computers and staff are on hand to help students who need additional support. Good arrangements are in place to support people to manage their own medication (or aspects of it) where appropriate and this again helps to maintain and promote people’s independence. Good formal and informal systems are in place to consult with the people who live at Stan Bell. Everyone has regular meetings with their key worker, formal meetings are held and there is a clear, accessible complaints procedure in place. What has improved since the last inspection? What they could do better: At the time of the inspection visit, seven of the eighteen people living in the registered service had been admitted out of category. This means that they have needs for which the service is not registered. This is a serious breach of the Care Homes Regulations 2001 and places doubt on the management systems within the service and the wider organisation. A safeguarding referral was made to Leicestershire Social Services for all seven of these people and for two other people who appeared to have significant needs in addition to their visual impairment. This was to ensure that people were not at risk by being placed in an environment not registered to meet their needs. The registered persons have been in discussion with the Commission and are taking urgent action to address this situation. A further unannounced inspection will take place before the end of the year to assess the progress made in making the following improvements: • The information that tells people about the home must accurately state which kinds of disabilities the service is registered to meet. This is to help people who want to use the service make an informed decision about whether it is able to meet their needs. The assessment process must be reviewed and improved. This is to make sure that the service has sufficient information about people to make an informed decision as to whether they can meet their needs. People living at the service must have a clear support plan in place, outlining how each aspect of their needs should be met. Written risk • • The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 7 assessments should identify particular risks for each individual and outline how they should be managed. • All staff must receive appropriate training so that they can meet the diverse needs of people living in the service. Two improvements are needed in relation to medication: • • Changes in the Misuse of Drugs Act means that the service must put in place specific storage for controlled medication. For people taking ‘as required’ medication there should be a protocol in place giving the name of the prescribing physician and the circumstances under which the medication should be given. When and how the medication should be reviewed should also be stated. 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. The Stan Bell Centre DS0000066472.V373338.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 The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is poor Information provided by the service does not accurately reflect its current registration status. Current assessment practice does not ensure that the service admits only those people whose needs it can meet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We asked for a copy of the current statement of purpose. There is no distinction made between what the college and the residential unit provides. The statement of purpose states that the college provides ‘education and training for disabled people 16 years and above.’ No mention is made of the registration category of the residential unit. The unit is currently only registered to provide a service for people with a sensory impairment. Although three of the four learners who responded to the Commission’s survey said that they had received enough information about the college, before moving in, one said, “We were not informed of the range of disabilities at Stan Bell.” Admission to the service is dependent upon individual residential assessment over a period of several days. We looked at the assessment documentation for two people in detail. These people did not have a sensory impairment; one had a combination of particular disabilities, which placed them in the category of mental disorder, one person had learning disabilities. This means that both people had been admitted to the home out of category. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 10 The focus of the assessment process appeared to be educational. Although other aspects of need were identified, care plans guiding staff on how to respond to these issues had not been formulated. The registered manager said that it was obvious in some cases that the background information they had received from placing agencies hadn’t been sufficiently comprehensive to allow for a full assessment. This has been recognised and the service is seeking to address this. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate People’s needs may not be met because individual support plans and risk assessments are not in place. People are supported to take decisions and develop their independent living skills. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection seven out of eighteen people living in the registered service had been admitted out of category; that is they had disabilities that the service is not registered to accommodate. Some of these people had behaviour that at times was challenging. No plans were in place to guide staff on their response to such challenges. The registered manager said that these kinds of plans were not in currently in place for any learner but that she had started to address this. There was a generic statement in some learners’ files as to how staff should respond to self-injurious behaviour but this was not tailored to individuals’ needs and basically gave advice to administer first aid and to seek medical help. Learners also had risk assessments in place for accessing the local The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 12 community. Again however, these were generic and did not take account of individual learners’ needs and challenges. Detailed plans were in place in relation to independent living skills and how these were to be developed. One learner explained that they had spoken at length with their key worker, identified their goals and developed a plan to help achieve these. The service has a very well developed key worker system and learners spoke very positively about their relationships with their key workers. Staff also said that this role was very satisfying and that they gained ongoing guidance and supervision as to how to undertake their duties. All four learners who responded to the Commission’s survey said that they could make decisions about what they did and make choices about the activities that they were involved in. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good People can choose to take part in a range of social and leisure activities and are supported to develop their independent living skills. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person living in the service is currently attending the RNIB’s College and some also attend additional provision at Loughborough College, with appropriate support. There is a study room in the Stan Bell Centre, equipped with computers, where learners can do coursework and receive support with this if required. There is a wide range of extra-curricular activities available, including several ‘clubs’ that learners can join such as the athletics, drama and art clubs. Other activities include yoga and bowling. One staff member is offering some learners additional lessons in Russian and German. There is also a singing and music group and the ‘Messy Room’ is well equipped with keyboards and pianos. This room also has a pool table. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 14 The University Chaplaincy visits Stan Bell every fortnight and learners have access to a multi-faith room. Learners are also supported to observe their religious and faith beliefs, e.g. during Ramadan they are supported to rise early and to eat early/ later. As outlined in the previous outcome group, great emphasis is placed on supporting people to develop their independent living skills. For example one learner will shop with staff support for the ingredients for a week’s breakfasts (which are taken in each person’s individual flats). Main meals are taken in the College restaurant and one learner commented, “The meals are really nice”. The Stan Bell Centre DS0000066472.V373338.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): 18, 19, 20 Quality in this outcome area is good People’s health and personal care needs are generally well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People’s personal care needs have been assessed and staff provide support where appropriate to meet these. Learners can and do retain access to GP, dental and optical services in their home areas but arrangements are made for them to register and receive treatment with local practitioners. In looking at the experiences of those people we case tracked there were several examples of appropriate referrals being made to outside agencies and specialists, where it was clear that a learner required specific, specialist support. Guidance and training had also been sought for staff in how to deal with specific health conditions, such as diabetes. Some learners administer their own medication and appropriate assessments as to their competence are in place. These are regularly reviewed. Staff administer medication for some people. The names of all staff who have received training in administering medication are listed at the front of the Medication Administration Record (MAR) together with samples of their signatures. There is a photo of each person on their MAR and the potential The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 16 side effects of each medication administered is also given. Information for monitoring a person’s diabetes was also clearly recorded in the MAR. Some people take ‘as required’ medication but there are no clear protocols in place to state precisely under what circumstances this medication should be administered. Because of recent amendments to the Misuse of Drugs Act, specific storage arrangements are required for controlled medication in all registered care homes. The separate storage should be a metal cupboard of specified gauge with a specified double locking mechanism. It should be fixed to a solid wall or a wall that has a steel plate mounted behind it with Rawl or Rag bolts. The Stan Bell Centre DS0000066472.V373338.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): 22, 23 Quality in this outcome area is adequate People can raise any concerns and know that they will be listened to. The service’s current admission policy may place some learners at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a formal complaints procedure in place, which is available in different formats. All four learners who responded to the Commission’s survey said that they knew who to speak to if they weren’t happy with anything and three out of four said that they knew how to make a complaint. The two learners spoken with both said that they had a very open relationship with staff members and felt that they could tell them anything and that “there is always someone to talk to if you need to”. One staff member also commented that the home was well staffed and that there were able to spend time just speaking to the learners and getting to know them. All staff employed by the service have had the necessary recruitment checks, including having their names checked against the vulnerable adults register and two references obtained before they start work. We sampled four staff recruitment records and all necessary documentation was in place. All staff have received training in safeguarding children and in protecting vulnerable adults. The registered manager was attending a conferencing on safeguarding on the day of the inspection visit and keeps up-to-date with current practice in this area. Good systems are in place for supporting people with their finances and full records are kept of all transactions where staff support learners in managing their monies. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 18 Each learner is given an electronic key, which allows them access to their own room, the communal areas of the service and their own flat. It does not allow them access to other areas of the building. The people who require the support of a registered care home are distributed throughout five flats and live alongside people assessed by the service as not requiring this level of support. As stated in previous outcome areas, at the time of the inspection seven people were living in the care home who had been admitted out of category, which means the home was not registered to meet their needs. Records of incidents indicated that some of these people display behaviour that may challenge, including destruction of furniture, physical and verbal abuse of staff and verbal abuse of other learners. Several learners were also identified as exhibiting self-harm but again clear and specific guidance on how staff should respond to this was not in place. Staff had not received training in this area. Safeguarding referrals were made to Leicestershire Social Services for all seven of these people and for two other people who appeared to have significant needs in addition to their visual impairment. This was to ensure that people were not at risk by being placed in an environment not registered to meet their needs and where appropriate plans of care in relation to aspects of their needs had not been put in place. The Stan Bell Centre DS0000066472.V373338.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): 24, 30 Quality in this outcome area is good Accommodation is clean and comfortable and appropriate adaptations are in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residential accommodation for the college consists of fifty-nine rooms divided into five flats of ten and one of nine. One flat is exclusively for the use of older learners (over 25). The service is registered for twenty people and these people live throughout the home in the remaining five flats, although the registered manager said that they considered compatibility when people were allocated a flat. Each learner has an electronic key, which allows them access to their own room and flat, to the communal areas but not to other learners’ rooms or flats. Flats are segregated by sex. Each flat has a kitchen/diner and these are used for breakfast and for some lunches and evening meals. Kitchen cupboards have signs on them identifying what is stored there. There are plans to increase the size of one of the communal areas (‘the messy room’) so that it can accommodate more people to do a wider range of activities. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 20 We looked at two study bedrooms, which although containing standard furniture had been personalised and reflected the learners’ own tastes and interests. The rooms are well equipped, have telephone points and internet access and are all en-suite. There is a toilet with access for physically disabled people within each flat. One flat has been adapted to meet the physical needs of the person currently living there. The fire alarm system includes flashing lights and facilities for vibrating alerts to be added for people with a hearing impairment. The system is linked directly to the fire station. On the day of the inspection all areas of the building were clean and tidy and fresh smelling. The four learners who responded to our survey said that the building was always fresh and clean. The Stan Bell Centre DS0000066472.V373338.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): 32, 34, 35 Quality in this outcome area is adequate Not all staff have received the range of training necessary to enable them to meet the full range of peoples’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four staff recruitment records were sampled; all necessary information, including Criminal Records Bureau checks and written references had been obtained before staff started work. Staff names had also been checked against the Protection of Vulnerable Adults Register. Staff receive a structured induction based on the Skills for Care ‘First Steps Common Induction’ programme and work alongside another staff member for their first two weeks. Of the three staff who responded to the Commission’s survey, two said that they felt that their induction covered everything they needed to do their job; one said that it mostly did. Staff responding to the survey also felt that they had the right support and knowledge to meet learners’ needs. Staff have received training in a wide variety of topics, such as working with people with Aspergers but not all staff have received the necessary training to prepare them to meet the wide variety of needs of learners currently living in the home. For example not all staff have received training in dealing with behaviour that challenges or in working The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 22 with people with learning disabilities. No staff have received training in working with people who self-harm, although several learners exhibit this need. The service should review its staff training to ensure that all staff receive appropriate training to enable them to meet the needs of the people currently living in the service. The training programme must also take account of any changes to be made in the service’s registration categories. We spoke to one staff member directly about their experiences of training and support. They confirmed that they had been given the opportunity to gain National Vocational Qualifications and felt that they had been given appropriate training to do their job effectively. They confirmed that they received regular supervision and that regular, recorded staff meetings took place. The two learners we spoke with were very positive about the staff team: “Care staff are brilliant, really nice, they’re really good to talk to.” “All the staff are very friendly” “We get all the help we need” The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43 Quality in this outcome area is poor Current management systems failed to prevent a serious breach of regulations, and potentially placed some people at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection visit, seven of the eighteen people living in the registered service had been admitted out of category. This means that they have needs for which the service is not registered. The service submitted an application in September to vary its registration, to accommodate people with learning disabilities and physical disabilities, as well as those with sensory impairment, the only category for which it is currently registered. The application also sought to increase the number of people that could be accommodated in the registered service from twenty to fifty. At the time of the inspection the Commission had not approved this application. The people living at the service who had been admitted out of category had been admitted prior to the application being submitted. Some of these people had needs not covered by the registration application. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 24 These actions constitute a serious breach of the Care Homes Regulations 2001 and place doubt on the management systems within the service and the wider organisation. The registered manager stated at the inspection visit that she was aware that people had been admitted out of category and that there had been a breach of regulations. Extensive discussions have taken place with the service as to the action the Commission requires to remedy this breach. The service is actively seeking to address the Requirements made at the end of this report and to rectify its registration status. A random unannounced inspection will take place before the end of the year, to assess the progress the service has made. The registered manager has been registered three times before and has experience of working with people with learning disabilities and challenging behaviours. She holds the Registered Manager’s Award and the Certificate in Management (National Vocational Qualification at level 4). She also holds a BTEC advanced award for working with people with learning disabilities. Established systems are in place to monitor learner’s satisfaction with the college. There are learners’ focus groups and meetings with the Learning and Skills Council. Formal learners’ meetings are held once per term and these are recorded. At the beginning of term, the quality manager for the college meets with learners to discuss the ‘Ten Golden Rules’; these are displayed on notice boards and address areas of respect and dignity. Staff have received training in moving and handling, first aid and in food hygiene. Fire systems and equipment have been appropriately serviced and tested. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 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 Standard No Score 1 1 2 1 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 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 2 X 2 X X 3 1 The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA1 Regulation 4 Requirement The statement of purpose must accurately reflect the registration status of the service to ensure that people are clear that the service can meet their needs. Assessment procedures must be reviewed so that they are sufficiently comprehensive in all areas, to ensure that only people whose needs can be met are admitted to the service. Each person must have a detailed plan, which outlines the care and support that they need This is to ensure that staff know how to meet people’s needs and that those needs are met consistently. Written risk assessments must be in place, which identify particular risks for each individual and how those risks should be managed. This is to ensure that people can take responsible risks without placing themselves or others in unnecessary danger. DS0000066472.V373338.R01.S.doc Timescale for action 12/12/08 2 YA2 14 12/12/08 3 YA6 15 12/12/08 4 YA9 13 12/12/08 The Stan Bell Centre Version 5.2 Page 27 5 YA20 13 Secure storage must be put in place for controlled drugs to meet the requirements of the Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 28/02/09 6 YA35 18 All staff must receive appropriate 28/02/09 training, to enable them to meet the diverse needs of people admitted to the home. A revised registration application must be submitted to the Commission for Social Care Inspection. This application must accurately reflect the registration categories that the service can reasonably accommodate. This is to ensure that the service is no longer in breach of the Care Standards Regulations, 2001 and is only providing a service for people whose needs fall within categories it is registered for and whose needs it has proven it can meet. 12/12/08 7 YA43 4 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 Refer to Standard YA20 Good Practice Recommendations Protocols should be in place in relation to ‘as required’ medication. These should state the name of the prescribing physician, under what circumstances the medication should be administered and by whom. The protocol should also state the arrangements for the review of the prescribed medication. The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 The Stan Bell Centre DS0000066472.V373338.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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