Care Home: Broughton House and College

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What the care home does well Students have good care plans that are looked at regularly to make sure that things are working well for them. Information about the care plans, and how well the students are getting on at the college can be seen in lots of different ways, such as DVD`s and photographs. This means that everyone can be involved, and understand the information. Students also have help to make their choices and wishes known, including pictures, symbols, and staff who can use sign language. There are lots of activities for students to join in with at the college, and in the local community. They have their own activity plans, which help them to learn new things as well as enjoy themselves. There are also lots ways for students to keep in touch with their family and friends such as emails, letters, phone calls and visits. Staff know the students very well, and know how they prefer to be looked after. The staff are well trained and they understand how to keep students safe. What has improved since the last inspection? Since the last inspection the college have made lots of improvements to the way they support students. For example, they have looked at the menus and added more alternatives for students to choose from. They have also bought a `web cam` so that students can see their relatives by using the Internet. There are new pictures and decoration around the college to give it a more homely feel. Some students earn money for work they do in the local community, and there are new recording systems to help them keep that money safe. The manager has also made sure that all of the college`s records are kept separate from other Cambian services. CARE HOME ADULTS 18-65 Broughton House and College Brant Broughton Lincolnshire LN5 0SL Lead Inspector Wendy Taylor Unannounced Inspection 5th August 2008 08:40 Broughton House and College DS0000002334.V369865.R03.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 Broughton House and College DS0000002334.V369865.R03.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. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broughton House and College Address Brant Broughton Lincolnshire LN5 0SL 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) 01400 272929 01400 273438 keith.salmon@cambiangroup.com www.cambiangroup.com Cambian Care Services Limited Keith Salmon Care Home 24 Category(ies) of Learning disability (24) registration, with number of places Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only:Care home only - Code PC To people of the following gender: Either Whose primary need on admission to the home are within the following categories: Learning disability - Code LD The maximum number of people who can be accommodated is: 24 2. Date of last inspection 10th August 2006 Brief Description of the Service: Broughton House College is registered as a residential care home and owned by Cambian Education Services Ltd. The home is situated in the village of Brant Broughton and provides a 52-week placement for up to 24 young people between the ages of 15 and 25, who have special educational and social care needs resulting from severe learning disabilities and autism coupled with complex behaviours which present challenges. The home, set in landscaped grounds, provides accommodation, education and therapeutic services. Accommodation consists of single bedrooms and a variety of communal areas located in five areas of the property; the main part of the home - York and Lincoln House, the Coach House, the Flat and Sandbeck House. The Statement of Purpose promotes an approach based on nonaversive positive intervention and the purpose is to develop each student’s independence through education in an environment that offers warmth, security, consistency and understanding. The extensive staff team receives training and development opportunities relevant to the educational and social needs of the service users. The registered manager told us that the current fees for the service range from £17408.95 to £266,387.31 per year. Information about these costs and the day-to-day operation of the college, including a copy of the last inspection report, is available from the main office in the college. Broughton House and College DS0000002334.V369865.R03.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 2 stars. This means that the students who use the service receive good quality outcomes. This key unannounced inspection took place over one day in August 2008, and lasted for approximately 7½ hours. Two inspectors were involved in the inspection. During our visit we were told, and we observed that people who use the service call themselves students. The care and support received by four students was followed in detail, using a method called ‘case tracking’. This method involves talking to the student and observing the care and support they receive. Students were not always able to tell us their views and opinions, so we used lots of other ways to get information, such as looking at care plans and general records in the college, talking to staff, sending questionnaires to relatives and staff, and looking around the college buildings. We also used information that we already had, such as a self-assessment completed by the manager, and the reports the college had sent us about things that have happened since the last inspection. Comments that were made by students, staff and relatives are contained in the body of the report. What the service does well: Students have good care plans that are looked at regularly to make sure that things are working well for them. Information about the care plans, and how well the students are getting on at the college can be seen in lots of different ways, such as DVD’s and photographs. This means that everyone can be involved, and understand the information. Students also have help to make their choices and wishes known, including pictures, symbols, and staff who can use sign language. There are lots of activities for students to join in with at the college, and in the local community. They have their own activity plans, which help them to learn new things as well as enjoy themselves. There are also lots ways for students to keep in touch with their family and friends such as emails, letters, phone calls and visits. Staff know the students very well, and know how they prefer to be looked after. The staff are well trained and they understand how to keep students safe. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 6 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. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Student’s needs are identified and understood by the service, because there is a good assessment process in place. EVIDENCE: Each care file we looked at had an assessment in place. They showed us that people who are important in student’s lives are involved in the process, for example families and care managers. Areas of the student’s life, such as health, behaviour, medical needs and emotional needs had been looked at. There is also lots of information about likes and dislikes, and how much staff support or equipment that they might need. Where students can’t make safe choices for themselves, such as when to leave the building or when to cross the road, this is identified and a plan is developed (see Standards 6-10). Some of the files do not give as much information as others, and the manager said that he would look at how they could add more detail to the files. Assessments show how students have differing needs that are special to them, for things like their religion or culture, but some did not give as much detail as others. We talked to the manager about this, and again he said he would look at how they could improve this in all of the files. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Students are supported in an individual and respectful way, by staff who understand their needs. Care plans ensure that their personal needs and wishes are met. EVIDENCE: All of the student’s personal files were laid out in the same way so that people know where to find the information. There are placement/care plans in each file, which show how student’s needs and wishes are being met. The plans cover areas such as levels of independence, likes and dislikes, preferred daily routines and communication. They record who the student’s key workers are, and who was involved in developing the plans. They use pictures in the plans to help students be involved where they wish to be. Some files did not have a lot of information about what individual students would like to achieve in their lives, and the manager said he would make sure that more information was added. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 10 The plans also show staff how to support students with behaviour needs in a very positive way. There is very clear information, including risk assessments, about how staff use physical support methods with individual students. Records show that this type of support is only used when it is absolutely necessary, and a report is made after each incident so that managers can see it is being used correctly (see Standards 31-36 also). Risk assessments are also in place for things like being in the local community, or for mental health needs. The care and support that students receive is reviewed regularly, and there are records to show this. The manager told us that they are using things like DVD’s and photographs to help present the information at meetings so that everyone, including the students, can join in. He said that they want to improve the way they help students to be fully involved in their review meetings, and are looking at ways to do this at the moment. The information that the home had already sent us shows that staff receive training in how to respect student’s right and wishes, and how to make sure that they are able to make choices for themselves wherever they can. We have recommended that care plans have some information in them to show how staff have considered new laws about how people are supported with decisionmaking. We saw that there are lots of ways to help students make choices, and staff use things like pictures, sign language, and objects to do this. We also saw that there is information around the home about advocacy support, which can help student’s say what they feel or want. Staff showed us that they understand the student’s needs very well. They spoke to them in a calm and respectful way, offered them choices in the right way, and they did things like asking permission before they went into student’s rooms. Surveys we received from relatives contained comments such as the home is ‘excellent’ and ‘it takes individual needs into consideration’. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Students’ benefit from activities that reflect their lifestyle, choices and their needs. EVIDENCE: Students take part in different educational and leisure activities. These include relaxation, drama, horse riding, household tasks, shopping, and swimming. The students likes, dislikes and needs are used to make plans about the different activities, and we saw that staff follow the plans. The students’ files showed that there are ways that the college check the plan is working and when to make changes. Students are supported to make choices about their activities including using pictures to show what they want to do. Staff were seen helping students to make these decisions and there are lots of photos around the college showing students enjoying their activities. Some students Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 12 also have the opportunity to do a paper round in the local village. This gives them a chance to be involved in the community and earn money. Staff were able to show that they knew about students’ different needs such as culture and religion. Some plans had more details about this than others. The manager said he would improve this in all the plans. Students are able to stay in contact with their family and friends outside of the college and this is part of their care plan. Family members said in surveys that they are very happy with the way this is done, and with the information they get about the students. Students use lots of different ways to stay in touch with their family. In the last year, the college has developed new ways to do this including using ‘web cams’ so students can see their family by using the Internet. Students also use email, letters, phone calls and visits from their family, as well as going to visit their family at home. One student told us about a family holiday that they had just returned from. Students have a well-balanced and varied diet using fresh ingredients. There is a planned menu that includes different options. This describes a 4-week period, but it changes every few months. This is used to plan an individual menu for each student that includes their choices as well as any special needs they might have. For example, two students have special meals because of their religion, and others because of health reasons. Sometimes a nutritionist looks at the menus to help students stay healthy. Staff can use a form to tell the cook if the students like the meal or not. Mealtimes are calm and not rushed with students able to make more choices such as what drink to have. If a student wants to eat something different, the staff support this, and during the visit a student was seen choosing a different meal with help from the cook. However, these changes to the menu are not clearly recorded and the manager said that this would be a good way to help plan future menus. Students are not involved in the general shopping for the college but the manager said there is a plan for students living in one area of the college to start doing this. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Students benefit from the health and personal care arrangements within the college. However some medication arrangements must be reviewed to make sure that students are fully protected. EVIDENCE: Information that the home had already sent us showed that students are supported to see people like GP’s, chiropodists, dentists and opticians whenever they have a need to. The records we saw in the home confirmed this, and showed that students have an annual health check with their GP, and regular reviews of their medication. There are detailed notes about any visits to see healthcare professionals, and appointments are written down so that they are not forgotten. We saw separate reports of any accidents or injuries, and the reports include what action staff take to deal with the situations. The records also showed us that students could see people like a psychiatrist, speech and language therapist or a psychologist if they need to, and these people visit the home regularly to provide support. The manager told us that at the moment he is arranging for other further services such as speech and Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 14 language therapy, to be provided regularly at the home. During the visit we saw staff helping students with their personal care in a private and dignified way, and that they encouraged a flexible approach to daily routines, for example what time they got up or what time they ate meals. Records for administering medication, and the arrangements for storing medication were satisfactory. The students that we case tracked all have help with their medication. The information we received from the home before the visit told us that risk assessments are in place for those who want to take their medication themselves. Staff told us that that they receive training in how to administer medication, and the community pharmacist visits every three months to check that they are doing things in the right way. We saw that in most cases there are clear instructions for staff about how to administer medication that is only used when necessary. We recommended that they have the same type of information for things like pain relief medicines, so that they are also given in a consistent way. We saw that when students leave the college for things like holidays or visiting their families, staff take the tablets out of their original packets and put them in to other containers. This is called ‘secondary dispensing’ and is considered to be unacceptable. We spoke to the manager, who stopped this from happening straight away and agreed to make other arrangements with the local pharmacy. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Students’ benefit from well-trained staff and from systems that protect them from harm. EVIDENCE: Records show that the college tells the local authority, and the police if necessary, about any situation that puts students at risk. Our records show that they also tell us. Since the last key inspection some issues have been reported to the local authority. One is still being looked at, but none of the others have been upheld. Staff have good training and they know about how to report any concerns. This training is part of their induction, and a new member of staff showed us that they knew what to do. A student also said “I’m safe here”. There is also a way for staff to tell the managers about anything else affecting students or the college. This is called a ‘cause for concern’ report. There are up-to-date records of these, showing what decisions were made. The manager has said he is looking into ways to help students let the college know about any concerns, especially those students who are unable to speak. There is a good system for making complaints and but there have been no complaints made since July 2007. There is a clear complaints policy in place Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 16 and relatives told us in their surveys that they know how to make a complaint if they need to. Students have support to manage their money, and records were seen showing that this is done safely. At a previous visit we said that the college needed to improve their records about students’ money, and this has been done. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Students have an environment that is safe, clean and well looked after; it has been designed to meet their needs and wishes. EVIDENCE: The students use buildings that have a good standard of hygiene and are tidy. In particular one of the newer areas of the college is modern and comfortable. Students can spend time in lots of different areas, and the buildings are adapted to meet their needs. Improvements have been made since the last inspection with new pictures and decorations put up to give it more homely appearance. On the walls, students can see photos of their activities and art that they have created themselves. There are plans to replace some of the windows, and for the courtyard area to be improved. There was some recent damage to paintwork. We were told that this is repaired on an ongoing basis. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 18 Each student’s bedroom that shows their individual needs and wishes have been looked at. One student said “I like my room”. It was noted that three bedrooms had ‘peep holes’ in the doors, meaning it was possible to see into those rooms from the corridor. The manager said that temporary coverings had been pulled off and permanent covers would be put on straight away to make sure that service users have privacy. They plan to replace the doors in the near future. There are records showing that the buildings are kept in good condition, and that the environment is assessed for any risks to students. There is information about keeping safe with any chemicals such as cleaning products. There is also information about hygiene, with signs about washing hands. There are gloves and aprons available. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Students are protected by recruitment procedures, and they benefit from a well-trained staff team. EVIDENCE: Staff files contained information such as two written references, application forms, CRB checks, and identification. Photographs of staff are available but are only used on identity badges. The manager said that he would make sure there is also a photograph on each file to help with identification. Staff told us about the recruitment process and said that they had to wait until the college had received all of the information before they could start to work with students. Records show us that staff receive training in subjects such as record keeping, physical interventions, medication administration, mental health, infection control, fire safety, sign language, and courses leading to a nationally recognised care qualification. Staff told us through discussions and surveys that the induction and training programmes are very good, and they help them Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 20 to understand the student’s needs better. They also told us that they only use physical support methods when all other approaches have been tried. Relatives told us in surveys that they think the staff are very well trained. The information the college sent us before we visited told us that some staff are trained to assess others during study towards nationally recognised qualifications in care, and that they continue to employ a staff development co-ordinator. The manager told us that the psychiatrist who supports the students provides some of the training about subjects such as epilepsy, autism, and new laws. Staff told us that they have regular supervision, and there are records to show this. They said that they can say what they think, and talk about their training plans. One staff survey said that when they have been involved in difficult situations, there is no opportunity afterwards for them to talk about how they managed in the situation. We discussed this with managers, who said that they would look to improve this area of support for staff. We looked at rotas and they show us that there are enough staff employed to meet the student’s needs. Staff told us that there are usually enough staff on duty, but numbers are sometimes reduced if staff are off sick. Some staff were off sick on the day of the visit but we saw that some students were still able to go out on a trip, and others were being supported with in-house activities of their choice. Staff were seen to work in a calm, unhurried way. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The college is well managed in the best interests of the students, and systems continue to protect the student’s health, welfare and safety needs. Quality assurance arrangements ensure that the service continues to develop. EVIDENCE: Since the last key inspection visit, the acting manager has registered with us. He told us that during the past year he has given more control over budgets to department managers, and there are plans to build another small house in the grounds of the college so that students have more choice of accommodation. He also said that he plans to review of the numbers of staff employed, to make sure that there is the right amount to meet the student’s needs. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 22 Staff told us that they have regular team meetings and good line management, but they would like to see more of the registered manager. He said that he usually tours the college three or four times a week and talks to staff and students, but he is always looking at ways to improve the contact with staff. There is an up to date fire risk assessment. Records show that there are regular checks on fire safety equipment, including alarms, and there are regular fire drills for students and staff. Records show that the last visit by the local fire officer took place in March 2007 and the outcomes were satisfactory. Water temperature checks are recorded regularly, and there are assessments and other information about substances that are harmful to health. There are clear records for each time a physical support is used, and when students or staff have an accident. These reports are reviewed regularly by senior managers, so that any patterns can be quickly identified. Information that the college gave us before we visited shows that there is a good range of policies in place such as, health and safety and risk management. We also know that there are policies for things like medication, first aid, complaints, and quality assurance. Our records show that the manager keeps us informed of anything that happens at the college that may affect the health or safety of students. Managers from the provider organisation visit the college regularly and write reports that tell us they are monitoring the quality of the service. They look at areas such as the environment, complaints records, safeguarding referrals, and individual student needs. Placing authorities also carry out visits to the home to make sure they are meeting the agreed contracts, and the report of a recent visit showed positive outcomes for students. Managers carry out regular audits for things like care plans, medical files and daily journals. Records of these audits show when paperwork has been completed correctly and on time. We suggested that the audits also look at whether there is clear information about things like how privacy and dignity are maintained, or how differing needs that are special to the student are supported (see Standards 1-5). The manager showed us that since the last visit, they have carried out surveys about staff stress levels, communication within the college, and meals/catering for students. Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 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 3 X 3 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 4 4 2 X 3 X 3 X X 4 X Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 24 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 YA20 Regulation 13(2) Requirement Dispensing of medication into containers other the original packaging, for the purposes of taking it out of the college must cease as it is unsafe and puts students at risk. Timescale for action 19/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA7 Good Practice Recommendations It is recommended that care plans include reference to the Mental Capacity Act, 2005 and the effects it has upon the student’s lives. This is to ensure that their rights and choices are protected. It is recommended that records are kept to show when students have chosen alternative meals to those on the menu. This is to ensure that those choices are fully recognised and incorporated into future menu planning. It is recommended that there are administration protocols in place for all medication that is given only when necessary, including pain relief. This is so that students receive all of their medication in a consistent manner. 2 YA17 3 YA20 Broughton House and College DS0000002334.V369865.R03.S.doc Version 5.2 Page 25 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. 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