Random inspection report
Care homes for adults (18-65 years)
Name: Address: Hesley Village and College Village Green Hesley Village and College Stripe Road Tickhill Doncaster DN11 9HH one star adequate service 01/06/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Sarah Powell Date: 2 5 0 5 2 0 1 0 Information about the care home
Name of care home: Address: Hesley Village and College Village Green Hesley Village and College Stripe Road Tickhill Doncaster DN11 9HH 01302866906 01302865473 craig.hardy@hesleygroup.co.uk www.hesleygroup.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Jeffrey David Cox Type of registration: Number of places registered: Conditions of registration: Category(ies) : The Hesley Group Ltd care home 68 Number of places (if applicable): Under 65 Over 65 0 learning disability Conditions of registration: 68 The maximum number of service users who can be accommodated is: 68 The registered person may provide the following category of service only: Care Home only Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Learning Disability, Code LD Date of last inspection Brief description of the care home Hesley Village is located in extensive grounds in a rural setting. It is just outside the village of Tickhill and approximately 8 miles from Doncaster. It provides accommodation for people with learning disabilities and complex needs.
Care Homes for Adults (18-65 years) Page 2 of 11 0 1 1 2 2 0 0 9 Brief description of the care home Hesley Village has a small shopping mall with bakery and grocery. There is a facility for people to collect their weekly monies and cash. The Hesley Group operate and audit this service. People at the village call this the post office and it is set up to look like a bank or post office building. The Village has a hairdressing and beautician salon, small cinema, and a restaurant. There is a medical room for people to use, to see visiting doctors and dentists. The Hesley Group manage and employ staff to run these services. The fees range from £178,810 to £249,492 pounds per year. This depends on peoples needs and level of support. Information about additional fees such as transport and other services is included in the service user guide. People who are interested in this service can get information by contacting The Hesley Group. The organisation will provide a copy of the statement of purpose and service users guide, and the latest inspection reports. Care Homes for Adults (18-65 years) Page 3 of 11 What we found:
This random visit was carried out as part of our inspection programme. Random means we will look at specific areas, this visit we looked at the outstanding requirements and recommendations from the previous inspection and other issues identified by placing authorities, completed surveys and safeguarding. The service had its last key inspection in June 2009 and achieved a one star adequate rating, which means the outcomes for people living at Hesley Village were adequate. A random visit was also carried out in December 2009 to determine progress with the requirements. We found good progress with the requirements and many had been complied with. A quality rating will only change following a key inspection. Therefore the rating for this service will stay the same following this random inspection. This site visit was carried out on 25 May 2010. Sarah Powell and Sharon Kelly Compliance Inspectors carried out the visit. It commenced at 09:00 and finished at 16:00. During the visit we talked to seven members of staff, two people living at Hesley and the Registered Manager. We also looked at care plans, menus, activity records staff rotas and other relevant paperwork. We looked at six peoples plans of care and other supporting documentation in detail to determine compliance with previous requirements. Only one of the four requirements had not been fully complied with, however it had been complied with in part, which showed good progress again and this ensured the service improved outcomes for people. The care plans had been developed in a new format with all information in one file. The new plans of care were easy to follow, clearly written and gave good instructions on how to meet peoples needs. It was evident from looking at the six care plans that care planning and recording had been comprehensively overhauled. In the vast majority of cases there was a clear support plan describing the steps staff needed to take to ensure that a person was appropriately supported, and a recording system for staff to record any notable interventions or incidents. All support plans inspected addressed whether the person had the capacity to participate in the planning process, although the quality of the descriptions about a persons capacity was variable, some just stated the person had no capacity to understand the plan, whereas they should detail the persons capacity regarding the care need. These plans were dated and reviewed, although as the new system is still in the process of implementation some reviews had taken place within days of plans being established. It is recognised, however, that this is a symptom of a new system being implemented and the timetable of reviews will become more meaningful over time. The risk assessments had also been changed, these again were clear and identified all peoples risk and detailed measures to take to ensure people were able to take risks as part of an independent lifestyle. All risk assessments inspected were in date and appropriate, including for those people
Care Homes for Adults (18-65 years) Page 4 of 11 whose risk assessments were using the previous model. Some housekeeping issues were identified within the new care plans, such as old recording systems being erroneously retained and in use alongside new systems. However the plans and risk assessments were work in progress and the Manager told us they should all be completed in the new format by June 2010. Daily journals were in place for each person and were completed by all support staff. These journals gave a clear description of the activities undertaken by each person and reflected the support plans that were in place, indicating that the support delivered is consistent with each persons plan. In one persons plan we looked at, there was clear evidence in the recording that a health issue had been identified. Following a hospital appointment in December 2009 a course of action was advised by the consultant. The records said this was on hold. However in the care plan there were no recordings as to what was happening to ensure the persons needs were met following the hospital appointment. We spoke to the care manager who told us that discussions as to the best course of action were still ongoing however she acknowledged this should have been recorded in the care plan so all staff were aware what was happening. One other person at our previous visit in December 2009 had advice from a dietician that wasnt being followed, this information was still in the care plan and was not being followed. It had not been reviewed to ensure their needs were met. It was clear from speaking to the staff this was no longer required so should have been reviewed and removed. Information we received after the visit showed the issues identified above were being dealt with. However the identified care needs in the plans of care that we looked at on the day of our visit, had not been updated on all occasions. A care management resources pack has been developed it contains advice and procedures to follow by staff to ensure peoples health care needs are met. One member of staff is responsible for implementing this and they have also improved joint working relationships with GPs, Primary Care Trusts and other health care professionals. this is to ensure peoples needs are met. We looked at night staff numbers as many issues had been raised in staff surveys regarding numbers of staff on nights not meeting peoples needs. We were told that a review of the night staff had been undertaken eight people required one to one staffing during the night and forty eight people were funded one member of staff to three. This arrangement required twenty four staff in total to meet contractual arrangements. However the layout of the service also had to be taken into account therefore a detailed night rota had been devised and 46 staff were on duty in total. The rota we were shown evidenced that adequate staff were on duty to meet peoples needs. We looked at activities for people living at Hesley Village. This had been identified at previous visits as not meeting peoples needs and parents had also mentioned in on the surveys returned. Excellent progress had been made in this area by staff, who were determined to improve external activities for people to ensure their recreational needs were met.
Care Homes for Adults (18-65 years) Page 5 of 11 Two activity co-ordinators were employed full time. As part of their job they were auditing activities arranged and correlating this against activities actually taking place. If they hadnt taken place responsible staff were accountable. They were also carrying out unannounced checks at activity venues where staff and people were meant to be. This was to ensue staff were aware of the importance of recreational activities on site and off site to ensure peoples needs were met. A staff survey had also been conducted to obtain peoples view as to how activities could be improved. A summary of the finding was given to us and most of the comments or recommendations that were reasonable and appropriate had been implemented. The approach to activities has changed substantially and it was evident on the day of the visit that people benefited form a wide and varied range of activities. It was evident that staff and management were taking concerns and recommendations seriously and recognised that activities had needed to improve. We had received concerns and a safeguarding alert regarding provision of meals. The allegation was that choice and flexibility had been taken away from people following changes to meal provision. We were told some people are participating in a trial whereby their lunch and/or evening meal is provided by the on-site brasserie. People can choose whether to eat this meal in the brasserie, collect it to eat at home, or have it collected on their behalf. Inspectors spent time in the brasserie and identified that on the day of inspection most people were choosing to eat at home. There was no evidence in the majority of care plans inspected that a decision making process had taken place to identify why a person was or wasnt included in the trial. The manager agreed to monitor the trial by completing the progress report in the plan of care daily for each person on the trial. Details to include time eaten, choice, if eaten in brasserie or collected, amount eaten and if it was enjoyed. This is then to be audited in four to six weeks to determine whether the new arrangements are meeting peoples needs. It would also be good practice to survey parents to determine what their views are to ensure they feel their son/daughters needs are being met. Prior to this visit we asked the manager at Hesley to send us information regarding safeguarding for the period 1/12/09 - 1/5/10. Their were nineteen alerts received, six of these were staffing issues that have been dealt with internally. Four were service user to service user these were well managed people were safeguarded following incidents and measures put in place to prevent future occurrences. Of the other nine, four were recorded as alerts but taken no further and the remaining five were investigated. Four have been concluded satisfactorily and one is currently being looked into by the placing authority. This is a substantial reduction in safeguarding incidents and ones reported were well managed and people were protected. We sent out survey to relatives and staff, we had 23 completed surveys returned from relatives and 11 from staff. The relatives comments were very positive praised the service, told us their relatives needs were met and staff looked after them very well.
Care Homes for Adults (18-65 years) Page 6 of 11 The only negative comments were regarding meals and activities, which have been improved and the changes are mentioned in this report. Most comments received from staff were also very positive most said it was a good place to work. Some commented on the changes to staffing on nights, however this was covered at this visit and outcomes in this report. Full feedback was given to the manager at the end of our visit. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking
Care Homes for Adults (18-65 years) Page 7 of 11 following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 8 of 11 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 9 of 11 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 19 13 Advice obtained from health 01/07/2010 care professionals that is not being implemented must be reviewed in the plans of care to explain the rationale for this. This will ensure decision making is transparent and that staff understand how to meet peoples health needs. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 2 6 17 That all peoples care plans are completed on the new format. That the new meals trial is monitored and reviewed to ensure peoples needs are met and peoples choices and flexibility is not compromised. To also document in plans of care a judgement why the person has been put on the trial. Care Homes for Adults (18-65 years) Page 10 of 11 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Adults (18-65 years) Page 11 of 11 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
