Review of compliance
National Star College National Star College - Ullenwood
Region: South West Ullenwood Location address: Cheltenham Gloucestershire GL53 9QU
Type of service: Care home service with nursing Specialist college service Date of Publication: August 2012
Overview of the service: The National Star College is a College of Further Education, providing residential accommodation for up to 88 students with physical disabilities and/or acquired brain injuries alongside associated learning, behavioural, sensory and medical difficulties. The main campus is based at Ullenwood Manor, situated in extensive grounds, above Cheltenham town centre. It is
Page 1 of 18 registered to care for people who require nursing.
Page 2 of 18 Summary of our findings for the essential standards of quality and safety
Our current overall judgement National Star College - Ullenwood was meeting all the essential standards of quality and safety inspected.
The summary below describes why we carried out this review, what we found and any action required.
Why we carried out this review
We carried out this review as part of our routine schedule of planned reviews.
How we carried out this review
We reviewed all the information we hold about this provider, carried out a visit on 11 July 2012, carried out a visit on 12 July 2012, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.
We were supported on this review by an expert-by-experience who has personal experience of using or caring for someone who uses this type of care service.
What people told us
We talked with eight students overall and observed support being provided to other students. We had a discussion with a group of four students. We talked about how they were involved in developing their care plans with input from their parents before they started at the college. They said they had copies of these plans which were kept safely according to their wishes and respecting their confidentiality.
Students told us they met with their key workers at least every two weeks to discuss their care needs. They said they were listened to and any changes which were needed were made to their care records.
Students said there were sufficient staff to meet their personal needs. They told us the staff/student ratio was very high. They recognised that the needs of students were changing and that some students needed more staffing input. They felt that there were enough staff to provide this support.
Students talked with us about opportunities for social activities both within the college and in Cheltenham.
Students in transition to other college accommodation next year or leaving college said they were well supported by staff. They said systems were in place to handover information to staff and other providers about the support and care they needed. Page 3 of 18 Students told us they felt safe at the college. They said if they had any problems they could talk to their key worker, senior staff or the Talk to team.
What we found about the standards we reviewed and how well National Star College - Ullenwood was meeting them
Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run
People's privacy, dignity and independence were respected.
The provider was meeting this standard.
Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights
People experienced care, treatment and support that met their needs and protected their rights.
The provider was meeting this standard.
Outcome 07: People should be protected from abuse and staff should respect their human rights
People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.
The provider was meeting this standard.
Outcome 12: People should be cared for by staff who are properly qualified and able to do their job
People were cared for, or supported by, suitably qualified, skilled and experienced staff.
The provider was meeting this standard.
Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care
The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.
The provider was meeting this standard.
Other information
Please see previous reports for more information about previous reviews.
Page 4 of 18 What we found for each essential standard of quality and safety we reviewed
Page 5 of 18 The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate.
We will have reached one of the following judgements for each essential standard.
Compliant means that people who use services are experiencing the outcomes relating to the essential standard.
Where we judge that a provider is non-compliant with a standard, we make a judgement about whether the impact on people who use the service (or others) is minor, moderate or major:
A minor impact means that people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.
A moderate impact means that people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.
A major impact means that people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly.
Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary changes are made.
More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety
Page 6 of 18 Outcome 01: Respecting and involving people who use services
What the outcome says This is what people who use services should expect.
People who use services: * Understand the care, treatment and support choices available to them. * Can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support. * Have their privacy, dignity and independence respected. * Have their views and experiences taken into account in the way the service is provided and delivered.
What we found
Our judgement The provider is compliant with Outcome 01: Respecting and involving people who use services
Our findings
What people who use the service experienced and told us Student's privacy, dignity and independence were respected. We observed staff treating students professionally, sensitively and with respect. Privacy was maintained for support with personal care. Staff supported students to be as independent as possible in their day to day lives. We observed students being offered choices about what they wanted to do and how to spend their time.
We had a discussion with a group of four students. We talked about how they were involved in developing their care plans with input from their parents before they started at the college. They said they had copies of these plans which were kept safely according to their wishes and respecting their confidentiality.
Students told us they met with their key workers at least every two weeks to discuss their care needs. They said they were listened to and any changes which were needed were made to their care records.
Other evidence Students who use the service were given appropriate information and support regarding their care or treatment. We saw copies of people's assessments, care plans and risk assessments. Students had been asked where they wished to have these kept. Some
Page 7 of 18 students chose to display them in their rooms whilst others asked for them to be kept in their wardrobes. Information was produced in accessible formats where needed using photographs and symbols to illustrate the text.
Students were supported to make decisions about their care. Where they refused support or treatment this was recorded. Staff made sure they gave people the opportunity to change their mind. Records were kept for key worker meetings evidencing any changes in support or care.
Student's preferences for support from male or female staff were noted. Care plans also identified student's religious or spiritual needs. Where students needed a specific diet or specialist support with their personal care this was recorded.
Student's independence was promoted enabling them to maintain or develop life skills. Students had the opportunity to access local towns and to take part in a wide range of community facilities and activities. Work experience and paid employment was also available for some students at the college.
Our judgement People's privacy, dignity and independence were respected.
The provider was meeting this standard.
Page 8 of 18 Outcome 04: Care and welfare of people who use services
What the outcome says This is what people who use services should expect.
People who use services: * Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.
What we found
Our judgement The provider is compliant with Outcome 04: Care and welfare of people who use services
Our findings
What people who use the service experienced and told us Overall we spoke with eight students and observed support being provided to other students throughout our visits. Students told us their care plans were provided in formats which were accessible to them. They said they could have an advocate if they wished.
Students said there were sufficient staff to meet their personal needs. They told us the staff/student ratio was very high. They recognised that the needs of students were changing and that some students needed more staffing input. They felt that there were enough staff to provide this support.
Students talked with us about opportunities for social activities both within the college and in Cheltenham.
Students in transition to other college accommodation next year or leaving college said they were well supported by staff. They said systems were in place to handover information to staff and other providers about the support and care they needed.
Other evidence Student's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We looked at the care needs of nine students using the service. An electronic database had been in use for two months in addition to paper records. Both were being maintained side by side and were current and up to date.
Page 9 of 18 We looked at specific aspects of students care such as their moving and handling, communication, nutritional or tissue viability needs. Robust records were being kept evidencing that student's needs were being assessed, monitored and responded to as changes occurred.
Care plans were person centred providing a clear overview of how the student wished to be supported. Student's physical, mental, social and emotional needs were considered. Any hazards were identified and strategies were in place to manage these risks. Reviews were being held with students and other people involved in their care.
We noted that students individual support plans cross referenced with other care plans and risk assessments providing a complete picture of each student's needs. For instance where a student was identified at being at risk of developing a pressure sore they had been provided with the necessary equipment. Their skin integrity was being monitored and any concerns raised immediately with the nursing team. Monitoring records were being kept where needed. We spoke with nine staff. They had a good understanding of student's needs and the support they required.
Any accidents or incidents were being recorded and followed up where necessary. Antecedent, behaviour and consequence (ABC) forms were being used to record and monitor incidents. Behaviour support plans were in place providing guidance for staff about how to support people when anxious or upset. Staff confirmed they had support of the 'Talk to Team' and a psychologist. Any restrictions or restraints such as use of bed rails or lapbelts were noted with evidence of the consent of the student for their use.
Students' health care needs were identified and appointments with the medical, therapy and wellbeing services provided by the college were recorded.
Our judgement People experienced care, treatment and support that met their needs and protected their rights.
The provider was meeting this standard.
Page 10 of 18 Outcome 07: Safeguarding people who use services from abuse
What the outcome says This is what people who use services should expect.
People who use services: * Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.
What we found
Our judgement The provider is compliant with Outcome 07: Safeguarding people who use services from abuse
Our findings
What people who use the service experienced and told us Students told us they felt safe at the college. They said the new security systems on campus were very good. They told us if they had any problems they could talk to their key worker, senior staff or the Talk to team.
Students recognised the need to inform staff of their whereabouts and to let them know when they were due to return to the college.
Other evidence Students who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Safeguarding procedures and systems were integrated into college services and into their home life.
Staff were trained in the safeguarding of children and adults. Those spoken with confidently described how they would identify, report and respond to suspected abuse. They gave a comprehensive overview of the systems the college had in place for identifying and reporting suspected abuse. They were knowledgeable about how to make sure student's stayed safe and what to do should they have doubts about the wellbeing of students.
Staff told us they recorded any significant events and these would be looked into by the college. We had not received any notifications from the college this year and there had been no safeguarding referrals.
Page 11 of 18 Staff had completed training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DOLS). No students were subject to a DOLS authorisation.
Students' records evidenced that they had given consent for their care and treatment. Each student had a financial support plan and risk assessment which identified whether they needed support from staff to manage their finances. Students had a safe in their room. Records were maintained where students needed support from staff. Other safeguards which were in place included an inventory of students' belongings.
Our judgement People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.
The provider was meeting this standard.
Page 12 of 18 Outcome 12: Requirements relating to workers
What the outcome says This is what people who use services should expect.
People who use services: * Are safe and their health and welfare needs are met by staff who are fit, appropriately qualified and are physically and mentally able to do their job.
What we found
Our judgement
The provider is compliant with Outcome 12: Requirements relating to workers
Our findings
What people who use the service experienced and told us We observed student's interacting positively with staff who responded to them appropriately and with understanding. Students told us that communication between themselves and staff was excellent.
Other evidence There were effective recruitment and selection processes in place. We looked at recruitment and selection files for six members of staff. Checklists were in place which provided a comprehensive overview of all the checks which had taken place prior to appointment. Each applicant had supplied an application form and where there were gaps in employment history these were followed up.
Robust systems were in place to verify and check applicants suitability for the position. References were obtained from employers over the previous five years. Where applicants had worked previously with vulnerable adults and children verification was obtained from these employers about why they left.
Evidence of the applicant's identity was obtained. A Criminal Records Bureau (CRB) check was received before applicants were appointed. Where concerns were raised about information supplied on the CRB this was risk assessed. Applicants were only appointed where the risks did not impact on students safety or wellbeing.
Where applicants were being employed from overseas the necessary checks about their right to work in the United Kingdom were being carried out. Checks were also in
Page 13 of 18 place to verify applicant's professional registration.
Applicants were asked to supply evidence of the training and courses they had completed. Human resources staff said that all new staff completed the college's induction programme which included mandatory training regardless of their qualifications.
Our judgement People were cared for, or supported by, suitably qualified, skilled and experienced staff.
The provider was meeting this standard.
Page 14 of 18 Outcome 16: Assessing and monitoring the quality of service provision
What the outcome says This is what people who use services should expect.
People who use services: * Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.
What we found
Our judgement The provider is compliant with Outcome 16: Assessing and monitoring the quality of service provision
Our findings
What people who use the service experienced and told us Students told us they had lots of different ways to feed back to the college about the service being provided. During our visit they had a full student meeting with senior management. There was a student union with student representatives accessible throughout the campus. They said they were listened to and that their ideas had resulted in positive changes.
Other evidence Students who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. Robust systems were in place to record conversations and feedback from students and their representatives. In addition there were many formal and informal ways in which students views could impact on the quality of the service they received. For instance full student meetings, representation on the student union, meetings with key workers and the complaints procedure. Students had access to the college intranet providing them with quick and easy access to feedback their views to the college via the Talk to team.
Last year's student perception survey of the college identified that students wanted campus lighting and signage to be improved. These improvements were made. They also identified that some residential areas could be improved. For instance providing high-low surfaces in kitchens. All kitchens in new accommodation and some refitted kitchens in older accommodation were fitted with high-low surfaces.
The college was inspected by Ofsted in June 2012. The overall effectiveness of
Page 15 of 18 provision was rated as outstanding.
A range of audits were being carried out for instance monitoring care records, incidents and accidents and health safety. Any incidents were recorded on a significant events form and monitored by the Head of Risk and Health and Safety.
The college had also completed its own compliance audits which monitored each residence in relation to the 16 key essential standards of quality and safety. Recommendations from these audits were checked upon at the next compliance audit.
Our judgement The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.
The provider was meeting this standard.
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What is a review of compliance?
By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care.
The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety.
CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care.
Where we judge that providers are not meeting essential standards, we may set compliance actions or take enforcement action:
Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. We ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met.
Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people.
Page 17 of 18 Information for the reader
Document purpose Review of compliance report Author Care Quality Commission Audience The general public Further copies from 03000 616161 / www.cqc.org.uk Copyright Copyright © (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified.
Care Quality Commission
Website www.cqc.org.uk Telephone 03000 616161 Email address [email protected] Postal address Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA
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