Inspection on 10/04/07 for Percy Hedley Foundation

This inspection was carried out on 10th April 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Percy Hedley Foundation 27/05/09

Percy Hedley Foundation 07/04/09

Percy Hedley Foundation 28/02/06

Percy Hedley Foundation 07/12/05

Percy Hedley Foundation 25/09/04

Percy Hedley Foundation 15/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Percy Hedley Foundation Chipchase House & Ferndene Station Road Forest Hall Newcastle Upon Tyne NE12 9NQ Lead Inspector Elaine Charlton Key Unannounced Inspection 10th and 27th April 2007 09:00 Percy Hedley Foundation DS0000000331.V330150.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 Percy Hedley Foundation DS0000000331.V330150.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. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Percy Hedley Foundation Address Chipchase House & Ferndene Station Road Forest Hall Newcastle Upon Tyne NE12 9NQ 0191 2381300 0191 2701290 sarahmccormick@percyhedley.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Percy Hedley Foundation Sarah Fielding McCormick Care Home 50 Category(ies) of Physical disability (50) registration, with number of places Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom residential accommodation with board and care is provided at any one time shall not exceed 50 men or women 28th February 2006 Date of last inspection Brief Description of the Service: The Percy Hedley Foundation is a registered charity caring for people with cerebral palsy and related physical disabilities. The Foundation also runs a school where there are boarding facilities for children. Both share the same management and administrative team. Accommodation at the home is made up of 34 single bedrooms and a three bed roomed self-contained flat, housing two people, in the main building. Four single self-contained bed-sits and 10 self-contained bungalows are located separately in the grounds of the home. The bungalows are found within a covered “street” known as Ferndene. There is a dining room on the ground floor of the main building attached to the main kitchen. Meals are prepared here for people who do not wish to make their own. At the entrance to the home there is a day centre that many people who live at Chipchase and Ferndene use. It has a separate lounge/dining area, and includes a bar that people from both residential and day care services use. Chipchase House is in a quiet residential area of Forest Hall close to a metro station and bus routes. Nursing care is not provided but staff are trained to carry out some delegated nursing tasks. Fees are between £633 and 710. The home has a new Residents Handbook that gives information about the support and care anyone living at Chipchase or Ferndene can expect. Copies of CSCI reports are available in the home. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was made on date the 10 April 2007, with a further follow up visit on the 27 April 2007. The manager was present on both days. Before the visit we looked at: • • • • • Information we have received since the last visit on 28 February 2006; How the service dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The provider’s view of how well they care for people; The views of people who use the service, their relatives, staff and other professionals who visit the service. During the visit we: • • • • • • • Talked with 16 people who use the service, 9 staff, the manager and visitors; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building/parts of the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit; Left “Have your say” questionnaires for service users to complete. We told the manager what we found. What the service does well: Helps people who live in the home to make decisions about what they want to do in a way that promotes choice and independence. Information is made available to people in a way that it is easy for them to understand. People who use the service are helped to get the equipment they need to keep them independent. People are consulted and involved in talks about alterations that affect their home. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 6 People who use the service can join in training with staff to increase their knowledge and help keep them safe. The Foundation continues to look at ways of improving the home for people who live there. Care plans reflect the expected benefits to people who live in the home. There is a wide choice of meals/snacks available at all times for everyone who lives in the home. CSCI receives a high level of co-operation from the manager and staff. People who live in the home said: “I do what I choose to do, I go where I want, when I want”. “I’m very happy here”. “It’s a nice home to live in”. “You can’t get anywhere better than here”. “I am more than happy to be here and do not wish to be moved”. “I always wanted to come here”. A health care professional said: “I think the residents at Percy Hedley are very well looked after”. What has improved since the last inspection? What they could do better: Care plan evaluations should be more outcome focused reflecting the benefits to people who receive support. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 7 Look at increasing staff skills in methods of communicating with people who live in the home. People who live in the home said: “Staff do not always have enough to time arrange visits to my elderly relative”. “Occasionally the staff do not have sufficient time to spend with me”. “Some staff do not understand me they just say yes or no and I always know when they do it and it really upsets me”. “Sometimes, if I am not using my communication aids, staff can have some difficulty in grasping what I mean”. 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. The summary of this inspection report can be made available in other formats on request. Percy Hedley Foundation DS0000000331.V330150.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 Percy Hedley Foundation DS0000000331.V330150.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are given good information to help them decide about moving into the home. Their needs and wishes are assessed before they are given the chance to move in. EVIDENCE: A new residents’ handbook has been put together with the help of people who live at Chipchase and Ferndene. It includes frequently asked questions, is in large print and has photographs of areas of the home and activities. Information was seen being made available in large print and on audiotape. As people need, information can also be provided in Braille or other languages. There are no people from an ethnic or minority background living at the home at the moment but staff know what they would have to do to make sure information was available in a suitable format. People are only admitted to the home following a thorough assessment process. The home has a waiting list of people who would like to live there. Strong links are maintained with school services and day services. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 10 Everyone has a service user plan that includes risk assessments and records of any interventions by health care professionals. People living in the home said they were given enough information about the home before they moved in. They also said: “I always wanted to live here”. “It’s a nice home to live in”. “You can’t get anywhere better than here”. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are involved in planning their care, making choices and decisions about what they want to do, and are helped to be independent in their personal care and daily life. EVIDENCE: Fifty “Have your say” questionnaires were left at the home for people to complete if they wished. Thirty-nine were sent back to the inspector. Thirty-three people said they always made decisions about what they did each day. Five said they usually did, and one said they sometimes did. One person said “ I do what I choose to do, I go where I want when I want”. Everyone said they could do want they wanted during the day, in the evenings and at weekends. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 12 Two members of staff are being trained in Person Centred Planning to promote the use of this process. Six service user plans were seen. All were kept in a standard way and included copies of care plans, evaluations, risk assessments and reviews. Some people had been given audio copies of their care plan. Records showed that people who live in the home are able to choose how they receive the support they need, from whom and at what time. They are asked about whether they would prefer male or female carers to support them. Care plans reflect the benefit to the person receiving care and/or support. For example, increased self-esteem, independence and self-image. This is good practice. Documents from each person’s initial assessment when they moved into the home are kept in their archive files with all other correspondence. Reviews are carried out six monthly. One is held with staff from day services. This arrangement is working well. Monthly care plan evaluations need to be more out-come based. People sign their care plans to show that they are in agreement with the content/arrangements. They are able to make choices about how they spend their time and where they wish to go. Some people use motorised wheelchairs and/or power scooters. them to get out independently to shops or social events. This helps Mail is only opened and acted upon if someone is in hospital. The limits to this arrangement are detailed in their care plan. Cultural and faith recordings are made separately and include arrangements in the event of a person’s death. At Christmas members of the St Aidens church congregation come to the home for a carol service. Everyone is encouraged and helped to manage their finances. access to personal lockable facilities or the home’s safe. They have Some people have personal communication aids to help them talk to their friends, family, staff and visitors. One person living in the home has a new, electronic, communication aid. The company who provided this are going to do some training so that everyone can get the best out of the equipment. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 13 People living in the home said: “Some staff do not understand me they just say yes or no and I always know when they do it. It really upsets me”. “Sometimes if I am not using my communication aid staff can have some difficulty in grasping what I mean”. “Occasionally the staff do not have sufficient time to spend with me”. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are encouraged to be as independent as they wish. They access educational and social opportunities within the home and the wider community. Choice and rights are promoted as well as healthy living. EVIDENCE: A list of activities that people take part in was seen. This was very long and varied and included visits to restaurants, pubs, theatre, concerts, snooker tournaments, football matches, speedway, fishing, pottery and other crafts. Photography, younger female nights, adult literature classes, live bands and entertainers in the day centre building, swimming and holidays. The inspector spoke to 16 people living in the home, all had recently been to the theatre, cinema or a social event outside the home. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 15 Several people are members of the Newcastle United Disabled Supporters Association and go to social events there. The cultural wishes/faith of people living in the home is recorded in their care plan. They are supported to attend local churches or meetings in the area. People are encouraged to maintain contact with their family and friends. It is sometimes difficult to provide everyone who wishes with transport to do this but most people receive mobility allowances to help with this. Staff will always try and get someone to their family if they are unwell. The home is a regional resource and attracts people from as far away as Strathclyde and Kirklees. Between these furthermost points staff at the home deal with 13 local authorities. Daily routines within the home were seen to be flexible and relaxed. Any limits to flexibility are only around people’s appointments, college or day centre commitments. One person is having a 40th birthday party in June. They have chosen to have the party at Chipchase and were heard discussing with the manager the need to choose a buffet menu. A beautician comes to the home regularly. service, as well as salons in the community. People make good use of this Mealtimes are flexible but also have to fit in with every ones activities. Breakfast is available from 08:00 to 09:30. A continental breakfast is served all morning; 12:00 to 13:00 is lunch; 17:00 to 18:00 evening meal; and 21:00 onwards, supper. Lunches and evening meals can be requested at other times. The chef has access to dietician reports to assist with meal planning. One person who is also diabetic plans a menu on a weekly basis with the help of staff. Menu choices are very varied and everyone spoken to was complimentary about what was prepared. Some people who live more independently prepare their own food. Others choose to have the occasional take-a-way. Percy Hedley Foundation DS0000000331.V330150.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are asked how they wish their personal care to be provided, and by whom. They are supported and helped to be independent with medication and can see health care professionals as their health needs dictate. EVIDENCE: Care plans reflect every ones need for support and or assistance with their personal care, how this should be provided and by whom. People handling assessments were seen. These support the safe use of equipment where necessary. Some people have their own equipment to health with bathing. Preferences for when people wish to take a bath, how they like to be assisted and whether staff should stay with them were sensitively recorded. Extra privacy screening has been provided in all the communal bathrooms that are also an escape route in case of fire. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 17 Everyone has access to a wide range of health care professionals depending on their personal need. One health care professional said they were consulted about how to manage and improve people’s health care. They felt staff respected everyone’s privacy and dignity. Details of regular visits to dentists, opticians and chiropodists were seen. Staff spoke knowledgeably about whether people were able to attend the health centre for appointments or whether they needed arrangements for the Doctor or Nurse to attend the home. Team meeting minutes show that staff have been prompted on issues of privacy, dignity and not excluding service users from conversations. Medication administration records (MAR) were seen for four people living in the home. Some minor recording issues associated with day centre attendance identified on the first day of the inspection were immediately put right. A new system for recording the administration of medication whilst people attend day services has been introduced. All medication was correctly stored and controlled. Refrigerator facilities for medications that need to be stored in this way are available. Refrigerator and treatment room temperatures are recorded daily. A thermometer has been provided in the treatment room so that staff can check the room temperature at any time. Disposal arrangements and facilities are in place for needles/patches or any other medication/equipment that needs to be disposed of in a particular way. People who live in the home are able and helped to be in control of their own medication. A health care professional said that this was always promoted where possible. Monthly audits of medications are carried out. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The views of people who live in the home are listened to. They are protected from harm through policies, procedures and staff training. They are also encouraged to join staff training to help them understand what happens when complaints, concerns and allegations are made. EVIDENCE: Thirty-nine people living in the home returned questionnaires. All said that they knew who to speak to if they were unhappy or wanted to make a complaint. The new Residents Handbook sets out what people can do if they are unhappy or wish to complain. It tells people they will be given a copy of the complaints procedure and that their views will be taken into account. Two people who live in the home sit on the Adult Services Committee and the Executive Committee where all major decisions are taken. They have full voting rights and put forward the views of people who use the service. Staff have received training in the Protection of Vulnerable Adults (POVA). People living in the home said that they had been also able to attend this training. This is excellent practice. The manager and staff record, investigate and report on complaints and protection issues in a consistent way. They are very pro-active when dealing with protection issues. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 19 The deputy manager is training as a POVA facilitator so that he can organise and deliver training in the home. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People live in a homely environment that promotes their independence and the chance to spend time privately. Everywhere is clean and tidy and hygiene routines are good. EVIDENCE: Alterations are about to start on the top floor to provide three people with private flats. Three bedrooms and previously shared areas are being combined to achieve this. The people who are going to live in the flats have been involved in the planning process and have made decisions about the layout of their personal space. This is excellent practice. A feasibility study is being carried out to assess whether and how further ensuite facilities could be provided for people living in Chipchase House. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 21 Two people showed the inspector their bedrooms that had been recently fitted with wardrobes, draws and storage areas. The home has a rolling programme of re-decoration for all areas. People who need to use wheelchairs can easily access their bedrooms through an electronic key system. Bedrooms are very individual and reflect the wishes, needs and interests of the people who use them. The bungalows, flats and uni-flats give people as much independence as they wish, the choice to cook or eat in the home and the space to spend time privately or to entertain guests, family and friends. Thirty-six people who live in the home said it was always fresh and clean. Two said it usually was. On both days of the inspection all areas seen were clean and odour free. Staff have the equipment and products to promote good hygiene routines. Training in health and safety and infection control is up to-date. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are protected by recruitment and selection procedures that are properly followed. Staff are supported through training and supervision to provide care to people in a way that meets their individual needs. EVIDENCE: Three files for newly recruited staff were seen. These are kept in a standard format and provide evidence of references, criminal records bureau (CRB) checks, identification and qualifications. The home’s recruitment and selection policy and procedures are routinely followed. A risk assessment was seen on the file of one employee who was pregnant. This is good practice. Sixty-three percent of care staff have gained a Qualification (NVQ) at a minimum of level two or above. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc National Vocational Version 5.2 Page 23 People living in the home have been able to join staff for training in POVA, fire safety and food hygiene. Nine staff spoke to the inspector. They gave positive feedback, said they felt well supported, got lots of training and confirmed that residents had been able to join training events. Key workers spoke knowledgeably and with confidence about the people they supported. The manager said people had been consulted about the change in key worker. They had been asked to list five people, in order of preference that they would like to be their key worker. The 2006/07 training programme included: • • • • • • • • • • • • Care of the person with cancer; Cerebral palsy awareness; Depression awareness; Fire safety; First aid; Food hygiene; Infection control Mental Capacity Act; Moving and handling; NVQ 2, 3 and 4; Safe handling of medication; Risk assessment. Planned training includes: • • • • • • • Registered Managers Award; Nutrition; Dysphagia; Epilepsy awareness; Continence management; Handling aggression; Control of substances hazardous to health (COSHH), and most of the courses on the 2006/07 programme. A health care professional said that staff had the skills and experience to support people’s social and health needs. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. They are The home is well run which benefits the people who live there. consulted about what goes on in the home through surveys and meetings. Both people living in the home and staff are protected through good health and safety procedures, systems and training. EVIDENCE: People who live in the home can speak to the manager, deputy manager or staff at any time. Team and House meetings are held on a regular basis. The inspector saw minutes of both meetings. Two people who live in the home sit on the Adult Services Committee and the Executive Committee where all major decisions are taken. They have full voting rights and put forward the views of people who use the service. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 25 Central heating, electrical and hot water systems are regularly checked and service arrangements are in place. Equipment such as the home’s lift and hoists are checked and serviced regularly as well as the emergency call and fire alarm systems. A contract is in place for the disposal of soiled waste and needles. All health and safety process are supported by clear policies and procedures that staff have easy access to. This includes infection control, control of substances hazardous to health (COSHH), fire safety, control of medication and disposal of clinical waste. The Foundation has put together Quality Assessment Standards and an Assessment Audit tool. This was done last year by a group, which included service users, staff from Northern Counties College, day and residential services and a parent representative. An independent consultant helped the group. Eight quality standards have been identified: Being treated as individuals and meeting personal needs, choice and flexibility, services and resources, friendship and advocacy, food, access to community resources, staff, environment and atmosphere. All sections scored highly for the quality of service. A report on the findings has been produced as well as an action plan to improve areas where satisfaction levels were not high. This is a very good piece of work. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 26 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 4 2 4 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 3 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 4 X X 3 x Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 YA6 YA7 Good Practice Recommendations Care plan evaluations should be more outcome based. Staff skills in methods of communicating with service users should be improved. Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Percy Hedley Foundation DS0000000331.V330150.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!