Inspection on 28/02/06 for Percy Hedley Foundation

This inspection was carried out on 28th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 10/04/07

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 Announced Inspection 28th February 2006 09:45 Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 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.V273163.R01.S.doc Version 5.0 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 7th December 2005 Date of last inspection Brief Description of the Service: The Percy Hedley Foundation is a registered charity caring for people with cerebral palsy and/or related physical disabilities. The Foundation also runs a school and have separate boarding facilities for children. All of these facilities share an upper management and administrative team in that they are all responsible to the Chief Executive. The home provides a diverse range of accommodation. Within the main building there are thirty-four single bedrooms located on wings. Each wing is equipped with a small kitchen/dining room and bathing facilities. There is also a two bed roomed self contained flat. A further dining room is attached to the main kitchen where meals are prepared for service users who do not wish to make their own. Within the grounds there are four self contained bed-sit flats, for single occupancy, each having a lounge, kitchen and bathroom. There are also ten self contained bungalows, each for single occupancy, within a covered street known as Ferndene. Each of these comprises a lounge, kitchen, bathroom and bedroom. Attached to the main building is a day centre which is used by many of the service users living within the Chipchase complex. The day centre is not inspected by CSCI. There is a separate lounge/dining area which includes a bar that is used by both residential and day care service users. Chipchase House is situated in a quiet residential area of Forest Hall but is also close to a metro station and bus routes. The well maintained grounds are equipped with greenhouses where some of the residential and day care services users work. A high level of personal care is provided but nursing care is not. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection by Elaine Charlton and Deborah Haugh took place on the 28 February 2006 at 09:45 and lasted until 15:15. The focus of the inspection was requirements made at the inspection on the 7 December 2005, and key standards which must be inspected at least once each year. Three staff files and training records, service user risk assessments, complaints, accident, fire, maintenance and quality assurance recordings were examined as well as policies and procedures relating to health and safety. The premises were inspected and this included, with the agreement of service users, a random sample of service users flats/bedrooms, communal bathroom and toilet facilities, shared kitchen areas, the laundry and storage/charging arrangements for wheelchairs and hoists. Prior to the inspection the manager sent copies of menus, staff rotas, activity and training schedules to the Commission for examination. As part of the inspection service users were also given the opportunity to complete a questionnaire about the quality of care provided. On the day of the inspection 22 responses had been received. Feedback and comments from the questionnaires are included in the body of the report. The registered manager, Mrs Sarah McCormick, was present throughout the inspection as well as David Fielding and Lorna Wills, deputy managers. All were well prepared for the inspection. What the service does well: The National Minimum Standards identify that 50 of care staff should be trained to NVQ Level 2 by 2005. This home exceeds the standards by having 71 of care staff trained to at least NVQ Level 2. This is commendable. Staff work with and respond to service users in a warm, relaxed and appropriate way. The service promotes the independence of service users enabling them to go out and about in the community and to manage within their own accommodation with the assistance of aids and adaptations. Service users are encouraged to be involved in the running of the home and can contribute to and influence change in a variety of ways. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 6 Comments from service users included; ‘I can come and go as I please.’ ‘I can close the world out.’ ‘Best decision I made to come here.’ ‘I’m very happy here.’ ‘I couldn’t have anything better.’ ‘I have the security of staff being around 24 hours.’ ‘Living here is better than living in the community, we have tried both.’ What has improved since the last 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. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were inspected on this occasion. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 9 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): 9 Risk assessments are in place to support service users maximise their level of independence. EVIDENCE: The content of risk assessments has been reviewed and they are signed by the service user concerned. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: None of these standards were inspected on this occasion. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: None of these standards were inspected on this occasion. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 12 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 and 23. Policies and procedures promote the acceptance, recording and investigation of complaints and service users can be confident they will be listened to. Policies, procedures and training ensures that service users are protected from potential abuse, neglect and self-harm. EVIDENCE: The complaints register was up to date and well documented but it is recommended that the format for recording complaints is changed to ensure they are numbered and include details of who has made the complaint, the substance of the complaint, the investigation, findings and whether the complainant was satisfied with the outcome. A recent investigation was carried out in a sensitive way and an appropriate range of professionals had been consulted including the Protection of Vulnerable Adults (POVA) team, Police and CSCI, resulting in a positive outcome for the service user concerned. All the service users who returned their questionnaire said they knew who to speak to if they were unhappy. Staff are aware of their duty to report bad practice and have received training in the Protection of Vulnerable Adults. Random audit checks are carried out on the records and monies held on behalf of service users. Income and expenditure sheets are currently initialled by Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 13 staff members. It is recommended that the latter are signed by the staff members involved in line with the Foundations policy. The staff handbook includes policies and procedures relating to: Concerns/complaints – including alternative people who will listen to a concern, expected timescales for response and how to contact CSCI, the Ombudsman and/or Ward Councillors; Missing persons; Handling residents cash/accounts: None of the service users who responded to the questionnaire said they felt unsafe living at Chipchase House or Ferndene. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 14 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, 27 and 30. The premises are homely and comfortable and provide a safe environment for service users to live in. All areas of the home are clean and hygienic promoting the health and welfare of service users. EVIDENCE: A tour of the premises was undertaken by both inspectors (separately) with senior members of staff. Ferndene consists of 10 individual bungalows where people are provided with aids and adaptations according to their assessed need. People have chosen their own decoration and furnishings and each bungalow is different and very homely. Each person has their own door keys and privacy is respected. Telephones, Internet access and fax machines are present where wished. The domestic staff were busy cleaning the bungalows but people themselves help to maintain their own homes as much as possible. Some of the bungalows are showing the effects of wear and tear due to wheelchair use. A continual maintenance programme is in place to update, repair as necessary. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 15 Chipchase House provides accommodation for 40 service users. There is one self contained flat. The self-contained flat and 7 bedrooms were viewed. All were very different and reflected the personalities and choices of the service users. The accommodation is spread over three floors, each of which has shared bathroom, toilet and kitchen facilities. Where service users have had difficulty with keys electronic entry systems have been provided to their bedrooms. Most service users have their own telephone, television and music centre. In addition to the main laundry a kitchen on the ground floor houses a domestic washing machine which several service users make good use of. Fire escapes on two floors are accessed through a communal bathroom. The fitting of an electronic override for the bathroom lock and a privacy shield for anyone using the bathroom at the time of a fire are being considered. Domestic staff were busy on each of the floors cleaning bedrooms and communal areas. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 16 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): 32, 34 and 35. Staff are competent, qualified and experienced ensuring that service users are well cared for. Robust recruitment systems ensure that service users are protected. EVIDENCE: The National Minimum Standard identifies that 50 of care staff should be trained to NVQ Level 2 by 2005. This home exceeds the standard by having 71 of care staff trained to at least NVQ Level 2. This is commendable. Staff photographs were in place in the 3 records sampled. Criminal Records Bureau registration numbers are recorded in staff files. Staff are employed in line with, and receive a copy of, the General Social Care Council Code of Conduct. The registered manager provided a list of the training which staff will have undertaken in 2005/6 prior to the inspection. Three staff files were sampled and a wide range of training was evident. Staff receive training and updates in health and safety covering fire safety, medication, food handling and moving and handling. Other training includes Protection of Vulnerable Adults, diabetes, cerebral palsy, depression, equal opportunities and challenging behaviour. The training arrangements are comprehensive. New staff receive induction and mandatory training. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 17 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, 39 and 42. The home is well managed to the benefit of service users. Quality assurance systems ensure that service users are provided with the service they need and want. Health and safety systems, records and maintenance contracts ensure that the safety and welfare of service users is promoted and protected. EVIDENCE: The registered manager is well qualified, experienced and competent to carry out her role. She is currently working towards obtaining the Registered Managers Award (RMA). The home has a quality assurance system and is also introducing Mulberry House system. Internal and external audits are undertaken. Service users confirmed that they are consulted about decisions which affect their lives. Monthly meetings are held at Chipchase House and Ferndene. Two service Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 18 users sit on the Adult Services Committee and Executive Committee where all major decisions are taken, they have full voting rights and represent people using the service. Fire, accident and maintenance records/contracts were examined and found to be up to date. Accident forms provided evidence of a manager monitoring the type of incident and whether any corrective arrangements should be made. The staff handbook provides comprehensive guidance on all areas of health, safety and infection control. A large room for storing and charging wheelchairs and hoists is located on the ground floor close to the laundry. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 4 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Percy Hedley Foundation Score X X X x Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 3 x DS0000000331.V273163.R01.S.doc Version 5.0 Page 20 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 3 4 Refer to Standard YA22 YA23 YA27 YA37 Good Practice Recommendations The layout of recordings in the complaints register, and numbering of complaints should be reviewed. Income and expenditure sheets for service users should be signed by staff. A suitable means of protecting a service users dignity in the event of a fire should be considered for the bathrooms that house fire escapes. The registered manager should complete the RMA by 2007. Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Percy Hedley Foundation DS0000000331.V273163.R01.S.doc Version 5.0 Page 22 - 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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