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Inspection on 29/08/06 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 29th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also 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

What has improved since the last inspection?

The acting care manager has been involved in the assessment of a potential admission and it is planned that he will have some involvement in all future assessments of residents to the Village Green, in accordance with his responsibility of ensuring that all residents are appropriately placed. The home is making good progress in streamlining the residents case files, and in introducing a care planning system relevant to the residents needs. Redecoration refurbishment and repairs have been carried out in residents accommodation as required. More staff are being enrolled onto NVQ training courses.The Village Hall has opened, that has facilities for residents to hold larger events like birthday parties, have a meal in the brasserie or restaurant, and visit the cinema if they want to. Staff are beginning to act as advocates for residents in areas of concern affecting their day-to-day lives in the home.

What the care home could do better:

There have been many developments made at the Village Green since the last inspection, and the home continues to make satisfactory progress towards providing the highest standards of care for residents. There are however a number of other issues found on this inspection that could be made to improve the situation as follows: It is important that all resident case file documentation is dated, particularly where staff are allocated responsibility for agreed action with residents. All residents must have the option of a minimum 7 day contracted holiday outside of the home, unless there are good reasons agreed with the placing authority that affects this decision. With regard to the resident`s healthcare, although some progress has been made to speed up the implementation of Health Action Plans for residents that were due in 2005, this still needs to be progressed on a continuing basis with the Community Adult Learning Disabilities Team in Doncaster. The home should also pay more attention to the health and safety issues concerning residents, particularly relating to the medication errors learned about on this inspection that can be potentially harmful to residents. In addition there is the continuing problem of wedged doors around the home that must be acted upon as advised by the Fire Officer with an alternative solution found as soon as possible. Continuing efforts must be made to improve the progress in enrolling staff to achieve the nationally recognised NVQ qualification, that should have been achieved in 2005.

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 Key Unannounced Inspection 29th August 2006 07:15 Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 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 NONE 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.V303045.R01.S.doc Version 5.2 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 i.e. washing machines x 2 are housed in the kitchens in this establishment. 20th February 2006 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. 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, together with a cinema, a brasserie, and a restaurant. 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 75) on site. Fees range from £166,272:00 - £248,824:00 as at 1st April 2006 and additional charges are made for annual holidays in excess of the contracted 7 nights, transport between the home and college for students or members of their families, overnight accommodation for parents who are visiting, pocket money, and special dietary requirements that cost in excess of a contractually agreed fee. Other additional charges are also made for hairdressing, aromatherapy, certain activities, and specialist magazines etc. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 5 The registered person makes information about the service available to residents and their families via the Hesley Group website, the Hesley Village and College prospectus, the Statement of Purpose, and the Service User Guide. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of bringing together the cumulative information and evidence received at CSCI, available to the inspector since the last inspection in February 2006, interviews with the people who use the service where possible, and interviews with staff on duty. It also included an examination of the homes records, and a tour of the accommodation. There was one resident aged 16 or 17 on this inspection. The inspection was commenced at 07:15 and finished at 15:00 and the inspector is grateful to all the residents, the assistant team managers, and staff who took part in this inspection. What the service does well: What has improved since the last inspection? The acting care manager has been involved in the assessment of a potential admission and it is planned that he will have some involvement in all future assessments of residents to the Village Green, in accordance with his responsibility of ensuring that all residents are appropriately placed. The home is making good progress in streamlining the residents case files, and in introducing a care planning system relevant to the residents needs. Redecoration refurbishment and repairs have been carried out in residents accommodation as required. More staff are being enrolled onto NVQ training courses. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 7 The Village Hall has opened, that has facilities for residents to hold larger events like birthday parties, have a meal in the brasserie or restaurant, and visit the cinema if they want to. Staff are beginning to act as advocates for residents in areas of concern affecting their day-to-day lives in the home. 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.V303045.R01.S.doc Version 5.2 Page 8 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.V303045.R01.S.doc Version 5.2 Page 9 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): 2. Quality in this outcome area is good and this judgement has been made using the evidence available and a visit to the home. The residents needs are met by a staff group organised and trained to provide care to the individual requirements of each resident. EVIDENCE: All residents continue to receive a thorough assessment of need, and the inspector was informed that the acting care manager (currently off sick) has been involved in the assessment of a potential new resident admission to the home. The inspector understands that all care managers will have some involvement in all future assessments of residents to the Village, in accordance with their responsibilities of ensuring that all residents are appropriately placed. A number of case files were examined which showed that a full assessment of need had been carried out, and the home has incorporated the requirements of this standard into its own assessment process. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 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. Quality in this outcome area is good, and this judgement has been made using the evidence available, and a visit to the home. The home is making good progress to streamline the residents case files, and to introduce a care planning system relevant to the residents needs. EVIDENCE: Plans of care were examined and found to be satisfactory, with the exception that there was an example where the minutes of a recent core group meeting were not dated, that would have made any requirements for action difficult for the staff involved to interpret. The plan of care is developed after a period of assessment, and in the case of any resident under 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 LAC review on the 27th July 2005, and Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 11 there is clearly another review overdue. The homes annual review was carried out on the 13th July 2006. 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 temporary accommodation (formerly 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. The inspector is aware that a “mock file” that has been trialled in Hesley Hall, and has been referred to the Principal of Hesley Village and College for authorisation, before being implemented The inspector is aware 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. Seven of the residents are able to communicate their views by speech, and four 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, and are now using a modified “sign along” to assist them, and also PECS, photographs, and anything else that furthers communication and offers support to them. Two residents have attended some part of their review, demonstrating the progress made by some residents on site. 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 all staff to attempt to teach potential dangers to residents, 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.V303045.R01.S.doc Version 5.2 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, 15, 16 & 17. Quality in this outcome area is good and this judgement has been made using the evidence available, and a visit to the home. Residents are provided with opportunities to maintain an appropriate lifestyle. EVIDENCE: There is a structure to the residents day involving the possible attendance at college that is within the village campus that can now be used as a “drop in” session. Staff also respond to the individual needs of residents by providing other structured programmes where appropriate, and there is also the option of using Doncaster College for specific courses where one resident already attends twice a week for pottery and life skills. The education department are also looking at colleges further a field for certain courses for residents at Goole and North Notts. College staff were on holiday during this inspection, and staff generally think that in order to provide a more complete service, the college should not follow the traditional education holiday timetable and programme, but should extend Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 13 their opening times to 50 –52 weeks per year to accommodate the needs of residents. Staff provide access to communal facilities for residents, and there are many visits to the local communities of Rossington, and Tickhill. Leisure activities are also undertaken, 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 use the Deaf School swimming pool in education time. Visits are also made to the swimming pool at the Dome in Doncaster, and usually take place in the homes vehicles. There are now 5 vehicles on the Village site, one for each registered unit, which enables more residents to enjoy off site facilities. Other activities include ten-pin bowling and ice skating at the Dome, and 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. One resident has a work placement at Sainsburys in Doncaster where he has a job shelf stacking, and he then goes on to Doncaster College in the afternoon to learn cooking skills. This resident also works in the bakery in the Hesley Mall, 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. One resident attends a conservation group at Fishlake, on a weekly basis, that enables him to meet other people and develop his community skills. Some residents have been to Center Parcs this year and there is another trip planned for November 2006. Three residents have been to Tideswell in Derbyshire for a holiday, but it was clear that not all of the residents will have a 7 day contracted holiday in 2006. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 14 A number of initiatives still in progress include residents being involved in paper re-cycling and collecting litter around the site. The introduction of the mall has enabled residents to collect their allowance from the post office/bank, and to purchase items from the grocery store and also from the clothing store established there. Staff continue to assess other residents for other activities that can be introduced in line with their capabilities. There is a possibility that residents may be involved in work placements at the RSPCA in Doncaster in the near future, and two residents attend the nearby Tickhill Garden Centre for social and recreational purposes. Many activities are organised in– house and there are extensive grounds in which to walk, that is a popular and regular activity. The public transport bus service still comes into the village campus, seven times a day between 07:19am, and 22: 15pm, and this is used by staff to take some residents into Doncaster/elsewhere either for educational or leisure purposes. Although voting cards are sent to the home, no residents have shown any interest in voting at local or general elections. The maintenance of family links is seen as being fundamentally important, and there is a regular interchange of parents and relatives visiting the school, and residents visiting and staying with parents and relatives. Three residents were absent staying with parents at the time of this inspection. Most residents have photographs of family and friends in their rooms, and all contact is recorded. In the event of any resident developing and maintaining an intimate personal relationship, the home would seek specialist guidance to enable the resident to make appropriate decisions, and a policy and procedure on this subject has been drafted for staff to consult in such circumstances. All staff respect residents privacy and knock on bedroom doors and wait a suitable time before entering. None of the residents have keys to their rooms at the present time because of their level of understanding. Some residents can open their own mail, and staff offer assistance and read it to other residents that are less able. Residents are generally addressed by their first names unless they or parents suggest differently, and this was seen to work adequately. Nicknames are not used. There are no pets at present, although this is always under consideration, together with a consideration of the advantages/disadvantages for residents. Meal times are flexible, and service users have 4 meals per day, and the main Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 15 meal is generally in the evening. The fact that attendance at college is now optional means that mealtimes are not necessarily structured around the college timetable. All meals in the Village Green are cooked by staff in the individual kitchens in the separate units kitchens, and sometimes residents help in meal preparation. All staff that cook, have been on food hygiene training. All residents are given one meal ticket per week that enables them to have a meal at the brasserie or restaurant in the Village Hall. Staff take service users shopping as and when required, and enable them to choose particular foods of their choice. There are drinks and snacks available at all times, subject to any restrictions on medical grounds, and fruit is available. A number of residents are on healthy eating plans and staff try to encourage them to eat healthily, that is sometimes very difficult to achieve. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 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. Quality in this outcome area is good, and this judgement has been made using the evidence available, and a visit to the home. All events that adversely affect the well – being or safety of residents must be notified to CSCI without delay. 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.V303045.R01.S.doc Version 5.2 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 are not as good as they should be, and Hesley management had corresponded with the GP practice over a particular issue. Hesley Village and College hope to have their own Nurse on site in the near future working from the medical centre for the benefit of residents, and the job has been advertised. The medical centre is also used by visiting dentists, opticians, and chiropodists etc, and other specialist services include access to a clinical psychologist, a consultant psychiatrist at Hesley Village and College and speech and language therapists as part of an overall approach to the healthcare needs of residents. Staff training includes being able to observe and recognise the early warning signs of ill-health in residents, and because of this knowledge staff are usually able to interpret residents needs to health professionals where they are not able to do it themselves. The Assistant Principal is aware that under guidance from “Valuing People, a new strategy for learning disability for the 21st century”, all residents should have had a Health Action Plan by 2005, and the GP surgery should instigate a version of this document based upon the residents having an annual health check. The inspector once again learned that the Hesley Group are currently considering Health Action Plans for all establishments and that work is in progress to introduce this document, and that there was a meeting for care managers on this subject on the 22nd May 2006. Contact with the Community Adult Learning Disability Team has been made and a meeting has been held seeking their advice on the required Health Action Plans for all residents. The home is still awaiting advice from the CALDT on the format of a Health Action Plan, but all residents have a comprehensive medical file, and there is also a medical audit sheet. All the residents healthcare needs are recorded and form part of their overall assessment of need. 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. Since the last inspection the home has notified three medication errors to Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 18 CSCI, but from reading the Regulation 26 visitors report of the 29th June 2006, it is apparent that five other medication errors/ incidents in June 2006 were not notified to CSCI in accordance with Regulation 37 of the Care Homes Regulations, and this must receive immediate attention. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is excellent, and this judgement has been made using the evidence available, and a visit to the home. Staff were seen to be acting for residents and highlighting their concerns, and in one instance recording a concern as a complaint. EVIDENCE: The home has a complaints policy and procedure, and a complaints record where any complaints can be recorded, together with details of any investigation, action taken, and the outcome. There have been two complaints/concerns received since the last inspection, that have been satisfactorily resolved. Discussions on previous inspections have 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 good to see that one of the recorded complaints was an example of a member of staff acting as the residents most immediate advocate and recording the complaint on their behalf. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 20 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. All care managers are now becoming more involved in abuse issues, and are attending strategy meetings and being involved in the internal investigations if required, which should enable them to fulfil their role as the care manager. There have been four “causes for concern” that have/or are currently being appropriately dealt with, but no adult protection incidents since the last inspection. The fact that staff are willing to voice their concerns and report any instances affecting the general welfare of residents in the home is commendable. The assistant team managers said that there is a new policy and procedure on how to deal with the overt physical and verbal aggression of service users, and staff receive training 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). The SCIP techniques are fully accredited with the British Institute of Learning Disabilities (B.I.L.D.) and promote the protection of residents. All interventions and incidents where any form of restraint has been used are recorded on an incident form as management information, and are checked by the team management to ensure that staff have acted appropriately. They are then routed via the on- site psychologists 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 the particular residents behavioural plans. A change to procedure recently introduced, 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 also learned that the incident forms have recently been amended to gather more information than formerly obtained. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 21 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 & 30. Quality in this outcome area is good, and this judgement has been made using the evidence available, and a visit to the home. Immediate attention must be paid to the issue of wedged doors if residents are to be safeguarded. 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) 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) Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 22 Village Green Bungalows (1&2) is 2 x 3 single bedroom bungalows with en suite facilities (Total 6). Although the accommodation continues to show the inevitable signs of wear and tear associated with a group living situation, 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, that appears to be working well. A random tour of residents bedrooms, communal areas, and bathrooms and toilets revealed a generally high standard of décor and maintenance. The inspector understands that the issues raised about the inconsistency in the heating systems in some units at the previous inspection have now been resolved. 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 and must be dealt with as a matter of urgency. The furnishings and fittings are of good quality, and the premises generally present as domestic in style. 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. 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.V303045.R01.S.doc Version 5.2 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. Quality in this outcome area is good, and this judgement has been made using the evidence available and a visit to the home. This outcome area has been affected by the low percentage of staff that have achieved their NVQ qualification, despite this being a requirement that should have been achieved by 2005. EVIDENCE: Staff receive job descriptions and conditions of service, and are aware of their own and other responsibilities with regard to resident care. 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. Staff also undertaking statutory training confirmed on this inspection, but despite the home being aware of the requirement for 50 of care staff to have achieved 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, this has not been achieved. The figure for the home currently stands at 15 for staff having achieved NVQ Level 3 and 5 for staff with NVQ Level 2. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 24 This inadequate situation has allegedly been attributable to the shortage of assessors and internal verifiers to progress the intake of candidates, and extra staff have now been recruited into this area to improve the situation. The problems of NVQ can be contrasted with the homes otherwise professional approach to training generally, and the inspector spoke to some staff that had been waiting for long periods of time to start NVQ training who were disappointed by the lack of progress. The inspector is aware that this is an area that is now receiving urgent attention, and it is hoped that that the target of 50 will be achieved by the end of 2007. Staffing levels were satisfactory on both the morning and afternoon shifts for 17/18 residents, including those residents requiring enhanced staffing cover above 1:1 cover. The files of three 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 the benefit of residents. A sample of supervision records checked showed that staff supervision was up to date, and there is a system of delegation to different levels of team management to achieve this outcome. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 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, 39 & 42. Quality in this outcome area is good, and this judgement has been made using the evidence available, and a visit to the home. The conduct and management of the home generally promotes the health and safety interests of residents and staff. EVIDENCE: The registered care manager is currently seconded to 49 King Street at Thorne, and is qualified competent and experienced to run the home, and has completed the Registered Managers Award. In her absence the Village Green is being managed by an acting care manager and an application has been made to register him as a care manager during the anticipated 12 months absence of the registered care manager. Staff confirmed that they were happy with the open approach of the acting care manager, and felt comfortable and at ease and able to raise any issue Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 26 concerning the care of residents. There is a recognised quality assurance system, ISO 9002, and in addition senior staff carry out an internal audit on all aspects of the care procedures on a continual basis, and verifies these audits on documentation designed for this purpose. An independendent person visits monthly as the Reg 26 (4c) visitor and prepares a report on the conduct of the home. 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. The Hesley Infonet is a computer system that provides access to policies and procedures and documentation on line. Developments have been finalised to incorporate a Hesley Group wide e-mail system, and 2-3 residents send and receive e – mails to and from parents, from the education block. Currently, the views of residents are sought directly and via parents and social workers, and the care manager contributes to the overall annual development plan for Hesley Village and College. All staff receive training in all aspects of safe working practices, including moving and handling, fire safety, first aid, and staff are aware of infection control procedures. The fire records were sampled and found to be satisfactory, and PATesting was completed in January 2006. The electrical hard wiring is not yet due to be tested. It was not possible to verify whether the oil boilers had been serviced because the records were not available, and the inspector arranged that this information be faxed to CSCI as soon as possible. The acting care manager receives his supervision and appraisal from the Assistant Principal to enable him 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.V303045.R01.S.doc Version 5.2 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 3 3 x x 3 x Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes 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 all resident documentation is dated particularly where action is required, as part of the overall care plan. 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 ongoing contact with (CALDT) is continued requesting advice on Health Action Plans for all residents. The registered person must ensure that residents are protected by the homes medication policies and procedures, and that all errors are notified to CSCI. The registered person must ensure that bedroom doors are not wedged open against Fire Service advice. Timescale for action 30/09/06 2. YA14 16 31/12/06 3. YA19 12 15/09/06 4. YA20 13 15/09/06 5. YA24 23 15/09/06 Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 Page 29 6. YA32 19 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. 15/06/07 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. 2. Refer to Standard YA37 YA42 Good Practice Recommendations The registered person should ensure that an application is submitted for the acting care manager to be registered as soon as possible. The registered person should ensure that all safe working practice certificates are available for inspection. Hesley Village and College Village Green DS0000046970.V303045.R01.S.doc Version 5.2 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.V303045.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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