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Inspection on 20/02/06 for Hesley Village and College Village Green

Also see our care home review for Hesley Village and College Village Green for more information

This inspection was carried out on 20th February 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

An accurate assessment of residents needs including specialist needs is obtained, and a plan of care is prepared and developed based upon the experience and changing needs of residents living there. The care manager anticipates being involved in the assessment process in future, to ensure that proposed residents are compatible with existing residents and can be appropriately placed. A multi-disciplinary team approach to resident care involving specialised interventions is pursued where necessary. The home continues to provide a welcoming and comfortable home, with a relatively stable staff group who work together as a team, and have a thorough knowledge of the residents and their needs. The home promotes the residents healthcare needs at all times and liaises with specialist services when required, and encourages independence within a framework of risk assessment. College attendance and work placements are encouraged, and there is a very full and active social life including holidays. Relatives friends and agencies, are encouraged to visit the home and maintain important links with residents.

What has improved since the last inspection?

The Statement of Purpose and Service User Guide have been updated so that residents and or their representatives are clear about the services the home provides.Arrangements have been made via a follow up letter sent in addition to the contract to notify residents/representatives of the room number to be occupied, to ensure that all residents enjoy a security of tenure during their stay at the Village Green. Progress has been made to arrange a holiday for residents, and also to implement a new repair and maintenance system. There is now a generic draft policy that includes guidelines on how to cope with residents who are incontinent. The staffing situation appears to have stabilised, and staffing levels were satisfactory without the need for much overtime having to be worked. Staff morale appears to have improved, and the health and safety certificates were available for inspection.

What the care home could do better:

The home must ensure that all residents files contain the necessary information to enable an accurate assessment to be made about the assessed and changing needs of residents, particularly in relation to individual living skills. All residents that are able must be offered the option of a 7 day contracted holiday outside of the home. Efforts must be made to speed up the time it takes to obtain replacement fixtures and fittings. Staff must not continue to wedge doors open against Fire Service advice and must seek urgent specialist advice as to how this matter can be amicably resolved. Attention must be paid to sorting out the heating systems in some units to make life more tolerable for residents and staff. Greater efforts must be made to enable more staff to achieve their NVQ qualification in the interest of residents.

CARE HOME ADULTS 18-65 Hesley Village and College Village Green Hesley Village and College Stripe Road Tickhill Doncaster South Yorkshire DN11 9HH Lead Inspector Mike Hamstead Unannounced Inspection 20th February 2006 07:20 Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 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 Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 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. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hesley Village and College Village Green Address 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 Village and College Stripe Road Tickhill Doncaster South Yorkshire DN11 9HH 01302 866906 01302 865473 Hesley Lifecare Services Eileen Champion Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users aged 16-17 years should not be accommodated in any unit containing other service users over the age of 25 years. As service users grow older, the registered person must inform the registration authority, of his proposals to manage incidents of incontinence, where current laundry facilities ie washing machines x 2 are housed in the kitchens in this establishment. 19th September 2005 Date of last inspection Brief Description of the Service: The Village Green is part of Hesley Village and College, and is situated in extensive grounds in a rural setting, just outside of Tickhill and approximately 8 miles from Doncaster. It is also close to the mining village of Rossington, and there are many staff employed from both villages. The Village Green provides accommodation for up to 20 residents, in individual accommodation and in a variety of different settings. There are college facilities available for residents from the entire village site including the Village Green, that are a short walk from the residents accommodation. There are also lots of other facilities for use in Hesley Hall, such as computer and video rooms, an activities room, a multi- gym, and a multi-sensory room, facilities for light craft activities, and also for dancing. In addition, there is the Hesley Shopping Mall that contains a post/office/bank, a bakery/grocers, and a clothes shop that are available for use by all residents at the Village Green. The Village Hall has recently opened, and there are also hairdressing and beautician facilities on site. There is also a medical room that is used by visiting doctors and dentists. The Principal of Hesley Village and College and member of the executive team is Sue Ekins, who has overall responsibility for the care of all residents (currently 73) on site. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 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 staff on duty, and an examination of the homes records. It also included a tour of the accommodation. Additional information of the overall situation had been gained from previous inspections, and knowledge of the homes Statement of Purpose. The inspection was commenced at 07:20 and finished at 14:35pm and included talking to members of staff relatives, and those residents that were able to communicate. What the service does well: What has improved since the last inspection? The Statement of Purpose and Service User Guide have been updated so that residents and or their representatives are clear about the services the home provides. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 6 Arrangements have been made via a follow up letter sent in addition to the contract to notify residents/representatives of the room number to be occupied, to ensure that all residents enjoy a security of tenure during their stay at the Village Green. Progress has been made to arrange a holiday for residents, and also to implement a new repair and maintenance system. There is now a generic draft policy that includes guidelines on how to cope with residents who are incontinent. The staffing situation appears to have stabilised, and staffing levels were satisfactory without the need for much overtime having to be worked. Staff morale appears to have improved, and the health and safety certificates were available for 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. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 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 Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 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, & 5. The Statement of Purpose, Service User Guide, and written contract/statement of terms and conditions, now provides all existing and potential residents with 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: There is a comprehensive Statement of Purpose that contains all the requirements outlined in Schedule 1 of the regulations, and also includes a statement of the aims and objectives of the home. There is also a statement of the facilities and services to be provided, and the fact that the home can provide care for residents that are 16 & 17 years of age. It also contains a description of what the home sets out to do specifically for young people under the age of 18 including the transition to adulthood. A condition of registration stipulates that any 16 and 17 year olds must not be accommodated with any resident over the age of 25, nor share the same communal space, and there was one resident under the age of 18 on this inspection. There is a Service User Guide, which is a pictorial/photographic representation that represented the homes considered view of the most understandable format that was appropriate for the majority of residents in the home, and Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 9 provided clear and accessible information for them. An alternative format has now been completed that includes some information in symbolic form to aid those residents who are more able to understand this presentation. All residents now have a hard copy of the Service User Guide. In addition, there has been some attempt to include pictures of a happy/sad format to try to get some residents to indicate whether they have any concerns in accordance with the homes complaints procedure. Residents also have access to a generic Service User Guide for the whole village complex and it is anticipated that interactive CD’s will be produced for individual units, demonstrating the groups desire to provide information in the most appropriate manner and in accord with residents levels of understanding. Additional charges are made for 2:1 staffing on days, and 1:1 staffing on nights to ensure that residents receive the staff deployment assessed for their needs, and also for hairdressing, specialised toiletries, and aromatherapy. All placements at the home are agreed with the respective placing authorities, and therefore the homes contract is agreed by them. There are no privately funded residents, but although the contract still does not specify the room to be occupied by the resident, there is a follow up letter sent in addition to the contract that specifies the room number, to ensure that all residents enjoy a security of tenure during their stay at the Village Green. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 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, and the care manager anticipates being involved in the initial assessments of new residents. There is a policy of continuing improvement in the provision of care documentation that augers well for the ongoing care of residents, but a review of file documentation is necessary to avoid duplication and wasted effort. EVIDENCE: Plans of care were examined and found to be satisfactory, with the exception that there was an example where information relating to a residents individual living programme had not been dated, following his admission in October 2005 nor had it been updated following the recent initial placement review. The inspector was informed by a member of staff that the resident was now shaving himself, (hand on hand) that had been mentioned at the review but this was not mentioned on the individual living programme. The plan of care is developed after a period of assessment, and in the case of any resident under Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 11 the age of 18 builds upon the Looked after Children documentation and arrangements of care made by placing authorities. It was seen that the file of the only resident under the age of 18 contained the Looked after Children documentation and arrangements of care made by the placing authority. There had been a review on the 13th February 2006 and also a LAC review. The files are comprehensive, but further streamlining is being considered. There are three different files for different functions, held in the main working area, and yet another file held in the Coach House containing initial admission information and including agreed contract information. Recommendations have been made in other reports in other units that a review of these files should be undertaken to eliminate staff’s duplicated effort and time in recording the same information in different areas that could be better utilised working with residents. One member of staff informed the inspector that an incident of a resident having an epileptic seizure would be recorded four times, and also mentioned at handover. The registered care manager mentioned that she anticipates being involved in all future admissions as part of her responsibility that new residents are compatible with the existing resident group and are appropriately placed, and this is to be commended, and is in the interests of the overall resident group. The inspector learned that a Placement Plan has been introduced for new residents, that will form the basis of a new care plan that will set out the care elements more clearly setting out the assessed needs and the objectives of the placement, and hopefully how these are to be met by designated staff in the home on a day to day basis. This information will then be updated as staff increase their knowledge of the residents needs, and will be reviewed on a regular basis and progress/ otherwise recorded to ensure that the home can continue to meet the residents needs. The Village Green has a maximum of 20 residents living there at one time and was fully occupied at this inspection, with one resident being returned by his parents having spent the weekend with them in Hertfordshire. The parents had returned for their sons review and were willing to talk about the excellent care given by staff to their son. Five of the residents are able to communicate their views by speech, and six other residents have some speech to a lesser extent that requires careful interpretation. The majority of residents have symbol key rings and other communication aids based upon individual needs. Staff communicate with residents to the level of their understanding, now using “sign along” to assist them, and also PECS, photographs, and anything else that furthers communication and offers support to them. One resident has attended the latter stages of his review, and another resident Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 12 has attended a core group meeting demonstrating the progress made by some residents on site. The care manager/team managers and clinical psychologist with responsibility for residents at the Village Green 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 is 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, in the best interests of the residents concerned. Placement reviews are carried out on a 6 monthly basis, usually an internal review, with the social worker, parents who are invited to attend, and where possible the resident. In addition staff from the homes 3 discipline areas of Care, Behaviour, and Education attend discuss and review the residents involvement and progress during the previous 6 months, and make recommendations for the next 6 months, which is the more comprehensive annual review usually attended by social worker and parents. An individual placement review is carried out after 4 weeks for Looked after Children, and formal reviews are then carried out 6 monthly for residents under 18 years of age, Staff assist residents in many different ways, ranging from assisting them with personal care, and ensuring their privacy and dignity is observed whilst bathing, and also being in close attendance while they were playing in their rooms. Alternatively staff walk around the grounds with them, go to the shopping mall, or go off site with residents providing supervision. Social workers and parents are contacted at a frequency as required within arrangements made at admission and always for health and safety issues. Generally speaking residents do not handle their own money, and six residents hold their own wallets whilst out shopping, but staff have responsibility for their money, and supervise purchases from the Mall, or elsewhere, when on trips outside of the home. The Principal is appointee for most residents DLA monies, and records of income and expenditure are maintained by the care manager, that are audited on a monthly basis. Risk assessments are available for every resident upon admission, and this is supplemented by the homes experience of the residents whilst in their care, when additional risk assessments are added if required. It is the role of the residents key-worker to attempt to teach potential dangers to them, Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 13 particularly road safety, but also dangers when staff take residents for walks around the building and along the perimeter of the grounds. There is a policy and procedure on how to deal with any resident that goes missing, but this has not applied since the last inspection and staff ensure that residents are supervised at all times. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 14 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): 14. Most residents are able to maintain appropriate and fulfilling lifestyles both in and outside the home. There are opportunities for personal development, and education, and community links are promoted. Regular communal and leisure activities are available, and contact with family and friends is encouraged and maintained. Some residents will not have a contracted annual holiday away from the home. EVIDENCE: Staff take residents on many visits to the local communities of Rossington, and Tickhill and staff provide access to a range of leisure activities, which as a result of experience varies between residents based upon their different interests and also their capacity to tolerate different events. Swimming is a popular pastime for many residents, and some residents were going to an arranged session at the Deaf School. Visits are made to other swimming pools in the area, including the Dome both in Doncaster, and Edlington swimming baths. These visits usually take place in the homes vehicles, and the inspector learned that an additional vehicle is to be purchased to make 4 in total, Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 15 ensuring an exclusive vehicle will be available for all the four units on the village site. Other activities include ten-pin bowling and ice skating at the Dome. One resident was going off to Sainsburys in Doncaster where he has a job shelf stacking, and then on to Doncaster College in the afternoon to learn cooking skills. This resident also works in the bakery, and accompanies the bakery manager to Batleys every Tuesday, to buy new stock. Another resident also attends Doncaster College for cooking theory, followed by cooking skills. Some other residents attend a conservation group at Fishlake, on a weekly basis. Additional leisure activities that include trips to the cinema, shopping centres, restaurants, public houses, seaside visits, and visits to other places of interest are undertaken. All residents are encouraged and supported to pursue their own interests and hobbies, and for some this includes obsessional activities, of various kinds to fulfil their needs. The care manager has arranged a holiday at Center –Parcs for 4 residents in 2005 for 5 days, and is trying to arrange for another 4 residents in March/April 2006. Another resident went to Tideswell in Derbyshire also for 5 days, and two other residents have been to Tideswell for a weekend visit. It is unlikely that all residents will have a 7 day annual holiday in 2005/6, and the parents of two residents have declined the holiday on the residents behalf saying that in their opinion it would not be suitable for them. The Hesley Village and College Prospectus for 2005/2006, now includes the fact that an aggregate of 7 nights annual holiday away from the establishment will be provided within the standard fees, and also a cost breakdown and responsibilities for payment of all aspects of such a holiday, in order that placing authorities are left in no doubt of the respective responsibilities for the funding of this contracted holiday. It is important that where possible staff ensure that all residents are offered an aggregate of a 7 day holiday away from the establishment, and where this is not possible this fact is communicated to placing authorities and parents and relatives. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 16 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 personal healthcare of all residents is promoted and specialist support is provided when necessary to safeguard their interests at all times. Health Action Plans are in the process of being devised for all residents. EVIDENCE: Personal support including intimate care is provided for all residents as required, and staff follow guidelines in this respect. Rising and retiring times are flexible, and assistance is provided with personal hygiene where required. Assistance is also provided with shopping where possible, and staff accompany residents to Doncaster or the Hesley shopping mall to enable them to choose their own clothes. The majority of residents are able to go off site, but for the few who are not yet ready to go off the village campus, the Hesley Shopping Mall is still proving to be a viable alternative. Although attendance at college is not a requirement of admission to the home, it is still seen as important by some placing authorities and parents alike, who understandably feel that a sense of order and predictability is all important in the lives of some residents. The residents immediate healthcare needs are the responsibility of the local Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 17 General Practitioner who via the PCT is allocated new residents as they are admitted, and will visit them in the home, or if they are well enough a member of staff will accompany the resident to the surgery as part of learning community skills. The care manager admitted that relationships with the local GP practice had improved considerably. All residents have access to all the other local primary health care facilities, and attend these facilities with staff accompaniment at all times accessing community services as part of their independent living skills. In addition, the home has access to a clinical psychologist, a visiting psychiatrist 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 their needs to health professionals. There is a policy and procedure for dealing with the ageing and death of residents, but the death of a resident in December 2005, in the nearby Woodland View was still a shock to all concerned, and staff are aware, that in some cases residents have complex medical problems, that require staff to be vigilant at all times. 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 an health action plan by 2005. 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 is a policy and procedure on medication requirements, and the MAR sheets were sampled in three units and found to be recorded satisfactorily. The medication was stored in clean and secure cabinets in all the areas. There were no controlled drugs being administered at the time of this inspection, and all staff administering medication have now received the accredited training, in the interests of residents. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 18 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 need to be reminded of their responsibility to act on residents behalf as an advocate in reporting residents complaints, but they are clearly willing to report potential Adult Protection issues to promote the protection of residents, that is commendable. EVIDENCE: There is a complaints policy and procedure, and the home has attempted to address the communication problems in respect of the complaints procedure in the Service User Guide, by producing it in a more appropriate and understandable format. 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 four complaints recorded since the last inspection. Discussions on previous inspections had been about the difficulties staff face in actually recognising when legitimate complaints are being made by residents with a learning difficulty, and the fact that because of the communication difficulties experienced by them, staff have to be diligent in recognising changes in their mood or behaviour that may indicate that something is troubling them. It was once again mentioned that consideration ought to be given to staff as the residents most immediate advocate recording complaints on their behalf, a simple example being them recording any lack of service previously provided to residents that had ceased or was taking a long time to be restored. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 19 There is a written policy on the prevention of abuse in its many forms to residents and also a whistle blowing procedure. Staff confirmed that they were aware of the procedures and had receive training on this subject. The home has established links between themselves and the appropriate persons in Doncaster Metropolitan Borough Council (DMBC), and now has its own Adult Protection procedure. Staff are also aware of the action to be taken in the event of a child protection incident, which relates to any service user under the age of 18, and the home has a copy of the local Area Child Protection Committee (ACPC) procedures. The care manager anticipates that she will be involved in abuse issues, and that she will attend strategy meetings and be involved in the internal investigations if required, which should enable her to fulfil her role as the care manager allowing her to be more aware of these situations than she has been in the past. There have been seven “causes for concern” that have been appropriately dealt with, but no adult protection incidents since the last inspection, but the fact that staff are still willing to voice their concerns and report any instance affecting the general welfare of residents in the home is commendable. There is a policy and procedure on how to deal with the physical and verbal aggression of residents, and training is given to all staff as part of the home’s positive approaches programme of training. This approach 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 team management to ensure their appropriateness. They are then routed via the on – site psychology service for them to analyse in terms of the residents overall behavioural programmes, and for them to decide whether or not there needs to be any amendments to particular behavioural plans. A change made since the last inspection is that if a supine or a seated wrap has been used as an intervention then the incident form has to be completed immediately and faxed to the Principal at Mallard House via the Therapeutic Behavioural Services Manager. The Inspector is aware that the above SCIP techniques, are fully accredited with the British Institute of Learning Disabilities (B.I.L.D.) Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 20 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, & 30. Continuing investment maintains the upkeep of the premises, but some areas still require attention. The subject of wedged doors continues to an item still to be resolved, and the care manager should pursue a meeting with the Fire Officer as soon as possible. EVIDENCE: The Village Green currently provides accommodation for 20 residents in individual accommodation as follows: Village Green House (1) is first floor accommodation for 3 residents in single bedroom en –suite accommodation, with an adjoining 1 bedroom bungalow with single bedroom en –suite facilities. (Total 4) Village Green Flats – ground and first floor accommodation for 2 residents on each floor all containing single bedroom en –suite accommodation. (Total 4) Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 21 Village Green House (2) is first floor accommodation in 2 x 3 bedroom semi – detached houses all with single bedroom and en – suite accommodation (Total 6) Village Green Bungalows (1&2) is 2 x 3 single bedroom bungalows with en suite facilities (Total 6). The accommodation continues to show the inevitable signs of wear and tear associated with a group living situation, but there is a planned maintenance and renewal programme for the fabric and decoration of the premises. Staff informed the inspector that there is now a new system for reporting repairs needed to the facilities manager, and once again there many examples of broken fixtures and fittings that staff said had been reported but where no action had been taken. These were referred to both the care manager and team manager for attention, and it was possible to see both a record of the date reported and an estimated date of completion supplied by the facilities manager. Some items however had not been logged as problems, and it is clear that there is a flaw in the system that needs to be resolved. In addition, the team manager acknowledged that some repairs are not done as fast as they should be, that is an unacceptable delay in an area that should receive immediate attention, especially where it affects residents quality of life. There were also issues raised about the inconsistency in the heating systems in some units, that also needs to be resolved with staff being informed of how they can regulate the controls as required. In addition and once again, there were a number of doors wedged open with cushions and doors across the various units, against Fire Service advice, but staff commented that there is a need for some doors to be kept open in order for them to observe residents and keep them safe. This situation has been a perennial problem since the home was first registered with seemingly no progress having been made to rectify the matter. The furnishings and fittings are of good quality, and the premises generally present as domestic in style, and the home provides all single room en – suite accommodation in a domestic setting that allows all residents to have their own possessions, and enables them to pursue their own interests and activities, and offers sufficient privacy. Not all of the bedrooms have all the furniture necessary to meet this standard, but for some of the residents additional furniture would be very difficult for them to cope with. The care manager has assessed the variable tolerance levels of residents to the additional furnishing requirements of this standard, and where it is identified not to be in their interests to have additional furniture in their bedrooms, has now recorded such omissions in their plan of care. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 22 Most residents have a television and various other items of electrical equipment such as video recorders, play stations, radios, and CD players in their rooms for their personal entertainment. There is a good range of communal space available for use by residents, which includes a kitchen/ dining area, and lounge area, and the style and quantity of furnishing in the communal areas, is domestic in appearance and is appropriate for the residents and meets the intended purpose of these areas. There are also lots of other facilities for communal use in Hesley Hall, a short walk away, such as : computer and video rooms, an activities room, a multigym, and multi-sensory room, facilities for light craft activities and also for dancing. In addition, there is the Hesley Shopping Mall that contains a post/office/bank, a bakery/grocers, and a clothes shop that are available for use by all residents at the Village Green. The Village Hall has recently opened, and there are also hairdressing and beautician facilities on site. There is also a medical room that is used by visiting doctors and dentists. There is a policy and procedure on the control of infection to ensure that the risk of cross infection is minimised, and staff follow guidelines on how to deal with soiled clothing and bedding in the various units subject to certain safeguards being followed. Staff said that they wore aprons and gloves when needed and strictly followed infection control procedures. The use and storage of chemicals is satisfactory, for the protection of residents and staff, and a draft policy and procedure on how to deal with incontinence is now available. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 23 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. The staffing situation has improved, and there is now a more stable staff team in sufficient numbers who receive regular updated training to meet resident’s needs, but further attention needs to be focused on staff achieving the required National Vocational Qualification. EVIDENCE: All staff have job descriptions and understand their own role and that of the wider organisation within the home. The home operates a keyworker system, and because of the high level of staffing cover provided, usually 1:1, they manage to acquire a comprehensive knowledge of resident care and other needs, but are aware of the need to involve other people with more specific expertise if necessary. There was evidence of a good interaction, between staff and residents, throughout this inspection as residents were either taken for walks around the grounds, taken out on leisure pursuits, or allowed to entertain themselves with a member of staff always in close attention. The home is now aware of the GSCC standards of conduct and practice, and all staff have received a copy. Volunteers are not employed, nor trainees under 18 years of age, and staff awaiting a CRB clearance are used on non care tasks always under supervision as seen on this inspection. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 24 The staff development and learning co-ordinator organises both statutory and job related training, for the benefit of residents, and staff continue to receive updated training, and regular staff meetings take place. 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 2005, but this has not been achieved, and currently stands at 11 . This allegedly is attributable to the shortage of assessors and internal verifiers. The home has not been able to register anybody for NVQ training for a year because of these difficulties and the inspector spoke to many staff who were frustrated about this lack of action, and to a number of staff who said that they had been asking to start the qualification for 2-3 years. This is clearly unacceptable, and is an area that must receive immediate attention if residents are to be cared for by competent and qualified staff. All staff left in charge of young people aged 16 and 17 when applicable are at least 21 years of age. The ratio of care staff to residents is determined by the high dependency of residents and is generally on a 1:1 basis. The home has 20 residents, and has two residents receiving 1.5:1 staffing cover. The staffing complement on the morning shift and afternoon shifts was satisfactory, and staff generally agreed that the overall staffing situation had improved. There is a recruitment policy and procedure, and the staff files for all Hesley Village and College employees, including those from the Village Green are held centrally, currently in the Coach House. A random sample of three staff files who had commenced employment since the last inspection were examined and found to be satisfactory, all containing 2 written references, and all containing either a file record signed by the Head that she had seen the CRB disclosures and/or a copy of the CRB disclosure itself. All staff receive a statement of terms and conditions, and are subject to a 6 monthly probationary period, and receive induction and foundation training, and also equal opportunities training, including training in epilepsy, by a disabled trainer. The training section maintains a “continuous training progress development” file for each member of staff, and ongoing and future training needs are identified via supervision and appraisal sessions. The homes induction programme from January 2004 is linked to the Learning Disability Award Framework - LDAF - accredited training as required by this standard, making it relevant to the care of the residents accommodated. A sample of staff supervision records showed that the frequency was at least 6 times per year promoting the interests of residents. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 25 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, & 42. The care manager has considerable experience of working in a senior position caring for young adults in this client group, at Fullerton House School as well as the Village Green and is using this experience to good effect in her present role. She continues to undertake periodic training and has recently achieved her registered managers award. EVIDENCE: The registered care manager is qualified competent and experienced to run the home, and has completed the Registered Managers Award. The registered care manager has been back in post since September 2005, following her covering for the position of care services manager whilst that person was on maternity leave. Staff once again confirmed that they were happy with the open approach of the care manager, and felt comfortable and at ease and able to raise any issue concerning the care of residents. All staff receive training in all aspects of safe working practices, including Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 26 moving and handling, fire safety, first aid, and staff are aware of infection control procedures. The home is trying to find another provider for food hygiene training and consequently there is currently a backlog for new starters. The fire records were sampled in two units and found to be satisfactory, and the servicing of the many oil boilers was carried out between the 17th – 19th June 2005. PATesting was completed in January 2006, and the electrical hard wiring is not yet due to be tested. The care manager receives her supervision and appraisal from the Care Services manager to enable her to continue to manage the Village Green in an effective and efficient manner for the benefit of all residents accommodated. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 x 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 4 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 2 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 4 4 x x x 3 x Yes. Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 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 YA6 Regulation 15 Requirement The registered person must ensure that residents/ representatives know that their assessed and changing needs are reflected in their individual plan of care. The registered person must ensure that all residents have the option of a 7 day annual holiday outside the home. The registered person must ensure that repairs to fixtures and fittings and redecoration of the premises receive immediate attention. The registered person must ensure that bedroom doors are not wedged open against Fire Service advice. The registered person must ensure that attention is paid to the problematical heating system in some of the units. The registered person must ensure that 50 of care staff achieve a qualification at NVQ Level 2, and that 80 of care staff working with service users aged 16 and 17 have completed NVQ Level 3 Caring for Children and Young People by 2006. Timescale for action 31/03/06 2. YA14 16 31/03/06 3. YA24 23 31/03/06 4. YA24 23 15/03/06 5. YA26 23 15/03/06 6. YA32 19 30/06/06 Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 30 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 Hesley Village and College Village Green DS0000046970.V282423.R01.S.doc Version 5.1 Page 31 - 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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