Inspection on 28/11/05 for 49 King Street

This inspection was carried out on 28th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

49 King Street 15/03/07

49 King Street 07/06/05

49 King Street 18/01/05

49 King Street 14/07/04

49 King Street 17/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 49 King Street Thorne Doncaster South Yorkshire DN8 5AU Lead Inspector Mike Hamstead Unannounced Inspection 28th November 2005 08:00 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 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 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 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. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 49 King Street Address Thorne Doncaster South Yorkshire DN8 5AU 01405 818580 01405 743110 christine.hobson@hesleygroup.co.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) Hesley Lifecare Services Christine Hobson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users aged 16/17 should not be accommodated where there are other service users over the age of 25. 7th June 2005 Date of last inspection Brief Description of the Service: 49 King Street is situated in the market town of Thorne, approximately 11 miles from Doncaster, and is situated in close proximity to the town centre and is close to public transport, shops, supermarket, post office, and health facilities. It is also close to both motorway (M18 and M62) and Thorne railway station, which provides regular access to Doncaster Goole, and surrounding areas. The property comprises a large detached six - bedroom house, (ex doctors surgery) with all bedrooms being on the first floor, and containing ensuite facilities. The ground floor facilities comprise of two separate lounges, a large dining room, conservatory, kitchen, cloakroom and utility room, and an activities rooms. The rear of the house includes a large private garden, with a terrace overlooking the lawned grounds, and private car parking, and there is a secure patio area at the front of the building. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of interviews with the care manager and all staff on duty, and an examination of the homes records. It also included a tour of the building to observe the accommodation. Additional information of the overall situation had been gained from previous inspection visits. The inspection was commenced at 08:00 and finished at 15:30pm and included talking to members of staff, and those residents that were able to communicate. What the service does well: What has improved since the last inspection? A policy on Emergency and Crises has been made available. The gas boiler servicing certificate has been made available. The Public Liability insurance certificate has been made available. Staff continue to undertake training to attain the NVQ level 2/3 training certificate. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 6 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. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 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 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1. The Statement of Purpose does not accurately reflect the service the home provides and potential residents/representatives would not have all the information about the home available to them to enable them to understand and decide whether the services the home provides meets their needs. EVIDENCE: The Statement of Purpose and Service User Guide, have now both been amended to show that the home is now part of Hesley Village and College at Tickhill, since responsibility for the overall management of the home was transferred, on the 1st July 2004. The care manager now reports to the Head of Hesley Village and College Sue Ekins, via the Care Services manager Tracey Mistry who provides line management supervision and annual appraisal to the care manager. The Head visits frequently to meet residents and staff. The Statement of Purpose for 49 King Street is contained within the overall prospectus devised and provided by Hesley Village and College for all its homes, but does not accurately represent the differences between 49 King Street and the other Hesley Village establishments. The aims, objectives, and philosophy of King Street have not changed ie to provide a placement for residents capable of living in the community as an alternative service to that 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 9 provided by Hesley Village and College, but these differences are not represented in the prospectus under the following headings: 1. 2. 3. 4. Community Links. Health Care. Organisation and Structure. Social Inclusion. The Statement of Purpose for the home clearly needs further work, to comply with the standard to enable prospective residents/representatives to have all the information they need in order to make an informed choice about where to live. There were no 16 and 17 year old residents accommodated at the time of this inspection, so it was not necessary to use the supplementary standards contained in the National Minimum Standards 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9. The individual needs and choices of residents are being met where possible demonstrating the availability of an accurate and ongoing assessment of all residents. All residents must be constantly reviewed to monitor the appropriateness of their placement at all times. EVIDENCE: Plans of care were examined and found to be satisfactory. All residents have plans of care that are updated as staff increase their knowledge of the residents needs, and are reviewed on a regular basis and progress/ otherwise is recorded to ensure that the home can continue to meet their needs. King Street is a small home with a maximum of six residents living there at one time but maximum occupancy has never been achieved. There are 4 residents at the present time but there is a possibility that two more residents may be admitted in the near future. The extent of the learning difficulties of some of the residents at King Street, makes it difficult for them to make some 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 11 decisions about their day to day lives without some form of staff assistance and guidance, and where this applies, it is recorded in their plan of care. Two of the residents are able to communicate their views by speech, and one resident has some speech that requires careful interpretation and uses PECS. Another resident has non verbal communication and has a sequencing board and a key ring with symbols on it. The care manager/team managers and clinical psychologist with responsibility for residents at 49 King Street also agree a behaviour management strategy for residents, and a specific individual behaviour plan for each resident. This documentation forms a planned strategy to address all identified behavioural problems and risks exhibited by individual residents. The plan sets out how challenging behaviours will be met via planned interventions by trained staff where necessary, and are reviewed on a regular basis to monitor progress or a change in behaviour. Staff monitor particular behaviours as requested by the clinical psychologist to provide relevant feedback for analysis by her. Any restrictions agreed concerning the freedom or choice of a resident are agreed in conjunction with all the relevant parties concerned, including the care manager care staff, especially the residents key-worker, the clinical psychologist, and dependent upon the circumstances is communicated to parents and placing authorities. This situation applies to one resident at the present time, because of his challenging behaviours that have involved assaulting and injuring a member of staff in August 2005. This incident highlighted both the vulnerability of King Street, in terms of staff deployment, ie there not always enough staff on site to assist with the challenging behaviours of residents, but also the benefits in relation to Hesley Village College as an alternative placement for one particular resident, because King Street is a smaller quieter environment, and it is known that the resident reacts adversely to noise that would be certainly increased because of the larger number of residents at HVC. Staff received specialised support from the clinical psychologist and consultant psychiatric services of Hesley Village College about this incident, but a recent review, was unfortunately not attended by the placing authority, nor the resident’s parents, but concluded that the resident was appropriately placed. Staff ensure that risk assessments are in place for all contingencies, both within 49 King Street, and when residents are escorted on external activities including recreational/leisure trips, that are reviewed on a 6 monthly basis, and amended, based upon knowledge of the particular and changing experiences of many residents 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14. Residents are able to maintain appropriate and fulfilling lifestyles both in and outside the home. There are opportunities for personal development, education and occupation, and community links are promoted. Regular communal and leisure activities are available and also an annual holiday. EVIDENCE: There is a vocational/activities timetable for all residents devised by staff, that includes a combination of vocational/life skills/activities at various educational establishments, Goole College, and Hesley Village College, as well as in-house teaching of independent living skills, and access to various commercial outlets for activities and shopping. The home has its own vehicle, but also uses public transport including the train for vocational and community recreational visits to enable residents to experience community involvement. Three of the four residents attend Hesley Village College for “drop in sessions”, for such diverse activities as horticulture art craft and woodwork, and the female residents have jobs in the Colleges hairdressing and beauty salons on 2 days per week. Residents also go horse-riding at Cantley on a weekly basis 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 13 and there is a variety of activities for them to enjoy. One resident is involved in a conservation group at Fishlake where he meets students from Hesley Village and College and he and another resident both attend a gymnasium at Moorlands prison in Doncaster, an activity carried on from his former placement at Fullerton House School and much enjoyed. All residents are known in the local community and go for walks into Thorne town centre, where they are known by shopkeepers and market stall holders alike. One resident has been risk assessed in this respect for damage caused to the window of a public house on one of these walks, but there has been no repetition to date. Community links are seen as important and enable residents to engage in conversation with the wider community. Residents also take part in shopping trips locally, and assist to pack the shopping bags, and there are other trips to Doncaster, Meadowhall, Cleethorpes Hornsea and car boots, to name a few. Leisure activities include swimming at a number of venues including Thorne and Goole baths that are used. Visits to pubs are also very popular, and residents attend a Men-Cap run youth club in Thorne every Wednesday who organise a variety of excursions for them. There are also visits to the cinema, bowling at the Dome, and staff use the local canal boat for pleasure trips that are all risk assessed to ensure resident safety. All residents went to the Hesley Challenge” at Hesley Village College in June 2005, and to Center - Parcs in October 2005 for 5 days, for their contracted annual holiday . 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 & 21. The promotion of personal healthcare and specialist support to residents is taken seriously and acted upon to safeguard their interests at all times. Health Action Plans are in the process of being devised for all residents. EVIDENCE: Personal support is offered to residents in many aspects of their day to day lives, from assistance with personal care, including suggestions about their appearance and what clothes to wear, and support is also provided with shopping where possible, and staff accompany residents to Doncaster or the Hesley shopping mall, and this is carried out in a manner that protects their privacy and dignity. There is a key-worker system in operation. Rising and retiring times are flexible subject to the requirements of college attendance, and residents can generally plan their day to suit themselves. Residents have some choice of the staff they would like to work with them, but are reminded that circumstances may mean that this is not always possible. The residents immediate healthcare needs are the responsibility of the local General Practitioner who has agreed to take on new residents as they are admitted, and will visit them in the home, or if they are well enough a member 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 15 of staff will accompany the resident to the surgery as part of learning community skills. All residents have access to all the other local primary health care facilities, and attend these facilities with staff accompaniment where possible, again accessing community services as part of their independent living skills. In addition, the home has access to a clinical psychologist, a visiting psychiatrist at Hesley Village and College and a speech and language therapist. Staff are trained to observe and recognise the early warning signs of ill-health in residents, and because of their knowledge are usually able to interpret residents needs to health professionals where they are not able to do it themselves. Residents are offered minimum annual health checks. All residents have a comprehensive medical file, and there is also medical audit sheet, and their healthcare needs are recorded and form part of their overall assessment of need. The care manager is aware that under guidance from “Valuing People” a new strategy for learning disability for the 21st century, all residents should have a health action plan by 2005, and the GP surgery has instigated a version of this document based upon the residents having an annual health check. The inspector learned that the Hesley group are currently considering Health Action Plans for all establishments and that work is in progress to introduce this document, that demonstrates the staff’s commitment to ensuring that the residents healthcare needs are met. There have been two visits to A&E for one resident, once with bruising sustained from another resident and the other visit for an ankle problem, and this also demonstrates a positive and caring approach by staff to resident’s healthcare needs. Three of the residents are on medication, and there is the possibility that the remaining resident may be prescribed medication to improve his quality of life following a meeting with the consultant psychiatrist. None of the residents are able to self medicate, and the MAR sheets were checked and found to be in order. There is a policy and procedure for dealing with the ageing illness and death of a resident that provides a holistic approach to the management of care. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Staff continue to have a greater knowledge and understanding of how to identify residents complaints and are to be commended for their willingness to report potential Adult Protection issues to promote the protection of residents. EVIDENCE: There is a complaints record where any complaints can be recorded, together with details of any investigation, action taken, and the outcome, and there have been two complaints recorded since the last inspection, one satisfactorily resolved and the other still ongoing. Considerable progress has been made by the care manager and staff in recent times actually recognising when legitimate complaints were being made by residents with a learning difficulty and recording them, as this had been a problem at previous inspections. There is a written policy on the prevention of abuse in its many forms to residents, and also a whistle blowing procedure, as part of a Child/Adult protection policy and procedure. Links have been established between the home and the Child/ Adult Protection Officers in Doncaster Metropolitan Borough Council (DMBC), and the process agreed by which any incidents of abuse have to be routed to the local authority as part of the Child/ Adult Abuse Prevention Process. Since the last inspection there has been one “cause for concern” reported by staff, that involved an alleged inappropriate intervention being used to a resident by a member of staff, that has been dealt with internally, and the care manager seeks advice from Adult Protection about such incidents. Once again, 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 17 this is another example that demonstrates the determination of certain staff to follow procedures and report any instance affecting the general welfare of residents in the home and is to be commended. There is a policy and procedure on how to deal with the physical and verbal aggression displayed by residents, and training was given to all staff as part of the home’s Positive Approaches programme of training in April 2005 that is based upon a positive intervention when necessary, and includes the SCIP technique (Strategies for Crisis Intervention and Prevention ) All interventions where any form of restraint has been used are recorded on an incident form, and are checked by the care manager/team managers, to ensure their appropriateness. They are then further analysed by the care manager who analyses them in terms of the residents overall behavioural programmes, and then in conjunction with the clinical psychologist, decides whether or not there needs to be any amendments to the residents particular behavioural plans There is a policy and procedure for residents monies and financial affairs, which precludes any staff involvement in the making, or benefiting from residents wills. One resident deals with her own monies and is very capable, and a sample of resident’s monies was checked and found to be correct and satisfactorily recorded. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 & 30. There is a welcoming and homely setting with suitable accommodation furnishings decorations and specialist equipment to meet all the resident’s individual needs and tastes. EVIDENCE: The home was registered in July 2003 and still continues to maintain a very high standard of furniture and fittings, in this relatively small group living situation. All accommodation is single bedroom en – suite accommodation, and in addition to having all en–suite facilities, there is also an additional bathroom and WC and a separate WC. The level of furniture, fixtures and fittings in the bedrooms are of a high standard and appropriate to meet the needs of the individual residents. Not all of the bedrooms have all the furniture necessary to meet this standard, because for some of the residents this would be very difficult for them to cope with and may lead to some furniture being damaged. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 19 The care manager has assessed the variable tolerance levels of residents to the additional furnishing requirements, and where it is identified not to be in the residents interests to have additional furniture in their bedrooms, has recorded such omissions in their plan of care. The four residents accommodated have a variety of equipment in their rooms, including television, and facilities for various other items of electrical equipment such as video recorders, play stations, radios, and CD players. One resident has sensory lighting in his bedroom, and another resident has his furniture and equipment securely affixed and protected because of his challenging behaviour in this respect. All bedrooms also have a telephone point connection, and the facility for an Internet connection, but are not used at the present time. There is a computer with Internet access available for residents use in the activities room. There is a planned maintenance and renewal programme for the fabric and redecoration of the premises, which is put into operation when required to maintain the quality of the premises for residents. None of the residents have a physical disability, and the home is accessible to them all, and the premises generally present as domestic in style. There is also a range of comfortable and accessible shared space, including 2 lounges, a dining room, conservatory, and an activities room. In addition there is a kitchen, reception area, utility room and an office. Externally in the front courtyard, staff have organised a sensory area in an area where residents have planted flowers, and herbs have been planted as well. At the rear of the home, there is a large lawn, together with an orchard and a summer house used by the handyman. One of the residents assists the handyman with odd jobs in the garden and residents bring plants from Hesley Village and College from their horticulture lessons there that are planted by the handyman with the occasional resident assisting him. Staff are aware of the dangers of being next to a busy main road, and residents do not leave the building from the front of the building. Further additional security measures including 3 star locks have been installed on one of the front gates to safeguard the welfare of all residents, and staff have completed risk assessments for all residents because of this hazard. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 20 There is a washing machine in the utility room, and the home has a policy and procedure on the control of infection to ensure that the risk of cross infection is minimised. One resident is incontinent at the present time and this is dealt with appropriately. The use and storage of chemicals is satisfactory, and the home was clean and hygienic for the benefit of residents. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 & 36. There is a stable and competent staff team in sufficient numbers who receive regular updated training to meet resident’s needs. Further attention however still needs to be focused on staff achieving the required National Vocational Qualifications. EVIDENCE: All staff have job descriptions, verified with those staff on duty, and staff are aware of their respective roles in relation to other staff including team managers, and the registered care manager. There is a good team spirit and there was evidence of a good interaction between staff and residents and the home operates a key worker system. All staff have received a copy of the GSCC standards of conduct and practice, and there is a volunteers policy, but there are no volunteers employed at present. All staff receive statutory training, and the staff hours allocated amounts to 7 days training per year, per member of staff to ensure that they can continue to meet residents needs. The home is aware of the requirement for 50 of care staff to achieve NVQ Level 2 by 2005, and/or 80 of care staff working with service users aged 16 and 17 to have achieved NVQ Level 3 Caring for Children and Young People by 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 22 2005, but this has not been achieved, nor likely to be achieved allegedly because of the lack of time for assessors to get involved. All staff left in charge of young people aged 16 and 17 are at least 21 years of age in order that they are able demonstrate a life awareness for the benefit of the younger residents. There were 4 residents accommodated, and there is a total staff complement of 28 excluding the care manager but including the team managers and assistant team managers, to cover all three shifts in the home. The staffing levels found on this inspection were above requirements, as the home was staffed up for the full occupancy of 6 residents. The ratio of care staff to residents is determined by the high dependency of residents, and the care manager is usually supernumerary, but covers for the team leaders and assistant team leaders when required to ensure staffing levels are adequate to safeguard residents at all times. At the present time staff work a days and afternoon shift pattern, and there are permanent night staff who are deployed on a 1:2 basis ie if the home is full with 6 residents accommodated, the staffing complement will be 3 night staff on duty. Staff training is the responsibility of the care manager in conjunction with the staff training and development co-ordinator at HVC and input from team managers at King Street. It is the care managers job to ensure that all staff receive the necessary training to meet residents needs. All staff receive induction and foundation training, and also equal opportunities and epilepsy training. A “continuous training progress development” file is maintained for each member of staff, and ongoing and future training needs are identified via supervision and appraisal sessions that are up to date and well organised. The homes induction programme from January 2004 has been linked to the Learning Disability Award Framework - LDAF - accredited training as required by this standard. The care manager and three team manager’s, have all achieved the D32/33 assessors award, and two other assistant team managers are due to start this training in 2006. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 23 The files of two new members of staff employed since the last inspection were checked and found to be satisfactory demonstrating a thorough approach to the recruitment and selection procedures to protect residents, and references are verified for authenticity. Regular staff meetings take place between the care manager and team leaders, and separate meetings between team leaders and care staff, as part of the homes thorough approach to resident care. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 & 43. Residents benefit from a well run home in their best interests, but staff should ensure that residents views are obtained on their lives in the home in order to identify and correct any problems. EVIDENCE: The care manager has delegated budgetary responsibility for the majority of expenditure headings incurred by the home in accordance with her position as the homes registered manager. Staff spoken to continue to be comfortable with the care managers style of leadership and approach to management, and repeated that they felt that their views were received well and considered objectively. There is a recognised quality assurance system, ISO 9002, and in addition the staff carry out an internal audit on all aspects of the care procedures on a continual basis, and these are verified on audit documentation designed for this purpose. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 25 An independendent person visits monthly as the Reg 26 (4c) visitor and prepares a report on the conduct of the home. The Groups own quality system, has now changed to the Hesley Infonet which is a computer system that provides access to policies and procedures and documentation on line. Further developments have been finalised to incorporate a Hesley Group wide e-mail system with the possibility of extending this for all residents but no residents at the home are currently using it. At the present time, the views of residents are not being sought directly in a formal manner via resident questionairres, but views are obtained from parents and social workers where possible. One resident currently talks and sees his parents via a video link on aweekly basis, and other residents have contact with parents and or social workers. The care manager develops and holds an annual development plan for the home that contributes to the overall Hesley Village and College annual development plan. She also ensures that residents continue to develop via lifelong learning opportunities, and this is considered in periodic reviews with placing authorities and parents. There is a self-advocacy action pack from DFES, written in an appropriate format for residents should they want and be able to use it with staff assistance. The care manager is hopeful of involving one of the residents with the advocacy service in the near future. As well as having a quality control audit, the home also has access to a specific person within the Hesley Group who is responsible for the development and implementation of the homes policies and procedures, who ensures that they comply with the relevant legislation. Since the last inspection a policy and procedure on emergency and crises has been made available to cover the emergency situation and evacuation following the homes electrical failure shortly after registration in 2003, and more recently the temporary accommodation of residents from Broughton Hall in Lincolnshire. All staff receive training in all aspects of safe working practices, including moving and handling, fire safety, first aid, and food hygiene, and staff are aware of infection control procedures that protects the safety of residents. The fire and gas servicing records were satisfactory, and the electrical wiring was checked prior to registration in June 2003, and PAT testing was carried out in January 2005 ensuring a safe environment for all residents accommodated. Risk assessments must be carried out on all aspects of this standard to further safeguard residents and staff, and the public liability insurance certificate was up to date and expires at the end of January 2006, protecting all people including visitors to the home. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 26 The care manager receives her supervision and appraisal from the care services manager as part of the overall management quality assurance that protects all residents in the home. 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23 Score 3 4 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 4 4 4 4 4 4 4 LIFESTYLES Standard No Score 11 x 12 4 13 4 14 4 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 3 3 4 4 3 4 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 49 King Street Score 3 4 3 3 Standard No 37 38 39 40 41 42 43 Score 4 4 2 3 3 3 3 DS0000044366.V266088.R01.S.doc Version 5.0 Page 28 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 YA1 Regulation 4 Requirement The registered person must ensure that the home has an up to date Statement of Purpose and Service User Guide . The registered person must ensure that resident’s views are obtained and included in the service user guide. Timescale for action 31/12/05 2. YA39 24 31/12/05 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 YA32 Good Practice Recommendations The registered person should ensure that 50 of care staff achieve a qualification at NVQ Level 2 by 2005, and 80 achieve NVQ Level 3 when working with service users aged 16 and 17 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 49 King Street DS0000044366.V266088.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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