Inspection on 07/12/05 for Percy Hedley Foundation

This inspection was carried out on 7th December 2005.

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

Other inspections for this house

Percy Hedley Foundation 27/05/09

Percy Hedley Foundation 07/04/09

Percy Hedley Foundation 10/04/07

Percy Hedley Foundation 28/02/06

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 Unannounced Inspection 7th December 2005 10:00 Percy Hedley Foundation DS0000000331.V261449.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.V261449.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.V261449.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.V261449.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 25th September 2004 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.V261449.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out by Elaine Charlton and Deborah Haugh on the 7 December 2005 at 10:00 and lasted until 14:30. The focus of the inspection was the key standards covering the welfare of service users, including social, educational and employment opportunities, daily routines, healthcare and medication. Six service user plans, daily recordings, medication records, menus and four staffing files were examined. The Inspectors had the pleasure of joining service users for lunch. During the day at least 12 service users were spoken to. The Manager and her Deputy supported the Inspectors throughout the inspection. Staff were helpful throughout the day and displayed a wide knowledge of the group of service users living in the home. What the service does well: What has improved since the last inspection? Two references are always obtained before a new member of staff commences work to promote the health, safety and welfare of service users. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Percy Hedley Foundation DS0000000331.V261449.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.V261449.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): 2, 3, and 5. The thorough assessment process enables service users to make a informed decision about the home’s ability to meet the needs and aspirations. Contracts are in place which support and protect service users living in the home. Service users choices, needs and wishes are clearly documented promoting their health, safety and welfare. EVIDENCE: A service user guide is in place detailing the services that can be expected by anyone coming to live at the Percy Hedley Foundation. Service users needs and wishes are clearly documented and a full assessment is obtained at the point of admission. One admission assessment also detailed “taster” sessions that the service user had had before making a decision to move permanently to the Percy Hedley Foundation. All service users have been issued with an updated contract in April of this year. One contract was not been signed by the service user concerned. Percy Hedley Foundation DS0000000331.V261449.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): 6, 7, 8 and 9. Regular reviews promote service users confidence that their changing needs and personal goals are reflected in their individual plans. Clear recordings indicate service users make their own decisions about their needs and how care is provided. Recordings and discussions with service users confirmed that they are fully consulted about all aspects of life in the home. More detailed risk assessments would support service users independence and protect their health, safety and welfare. EVIDENCE: Service users records are person centred and look at a range of needs and wishes. Personal preferences, strengths, needs and wishes are identified. There was no new risk assessment in place following a service user being involved in a scalding incident. The format used for recording risk Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 10 assessments is basic and does not indicate who has carried out the assessment or when it should be reviewed. Records included the use of food and liquid intake charts when appropriate and these were fully detailed. Turning charts were in place for one service user and these were dated, timed and signed by both members of staff in attendance. Records also indicated when a service user had made a clear choice about not wanting staff assistance at a particular time. It was also clear that staff acted promptly when service users raised concerns about health issues. The Deputy Manager was very clear about where and what was recorded ie., the handover book, occurrence sheets or whether a more confidential record should be made. Records were signed by service users to indicate their involvement. Service users said that they went out when they wanted, had had the opportunity to go away on holiday and were supported by staff when appropriate. One service user said he regularly went to do his shopping in the local area. One service user also said that they “get whatever they want”. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 11 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): 11, 12, 13, 14, 15, 16 and 17. Service users have access to a range of opportunities for personal development, social, community and leisure activities which promote their independence. Personal and family relationships are encouraged and supported to maintain service users inclusion and independence. Service users rights are respected in a way that promotes privacy, choice, dignity and independence. Mealtimes are flexible, the menus are nutritious and varied and promote service user choice and access to a healthy diet. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 12 EVIDENCE: Service users are able to access educational opportunities to develop their own skills. The range of social opportunities that the service users told the Inspectors about included going to church, family contact, shopping, going out to shows, the theatre and football matches. Staff were seen consulting with service users about whether they needed assistance putting up their Christmas decorations or wrapping presents. Service users were seen collecting their mail from the office on the ground floor and said that staff would read letters to them if this was necessary. Open house meetings are held and the minutes are read out to service users. One service user said that he encouraged others to attend the meeting and not to expect someone else to speak up for them. Meal time arrangements are flexible, varied and nutritious. Service users were seen to be provided with appropriate and discrete assistance where necessary in a pleasant and relaxed atmosphere. Lunch was seen to be a very social event. Service users are able to choose whether they have lunch in the dining room or make their own arrangements in their private accommodation. A weekly menu is displayed but in addition at least 11 service users have their own menu drawn up to meet individual needs and tastes. Service users confirmed that they could make choices about what they wanted to eat and that alternatives were readily available. The kitchen store rooms are well supplied with good quality “branded” products. The chef and kitchen staff also prepare meals for the day centre and this can be as many as 160 per day. The manager confirmed that a ceiling had been put on the number of meals that could be prepared as the size of the kitchen and equipment available limit the number of staff that can work safely together. A new enterprise is to commence in the day centre where a soup and sandwich quite room is to be provided and service users will prepare the sandwiches on a daily basis. This may alleviate some demand on the kitchen. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 13 One kitchen store room is sited away from the main kitchen and this requires staff to be organised early in the day to ensure that all dry goods are collected for that day. On the afternoon of the inspection work was underway to ice the Christmas cakes that had been made. The kitchens and associated areas were found to be clean and tidy and managed in an organised way. Fresh juice and fruit was available to service users who were seen taking items away with them for later in the afternoon. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Recordings about how personal support is to be delivered promote the choice and preferences of service users. Access to a range of appropriate health care professionals ensures service users physical and emotional needs are met. Systems, policies and procedures in place for dealing with medication promote self-administration, independence and the health and safety of service users. EVIDENCE: Care plans are explicit about the level of personal care service user require and how this should be given. Reviews are carried out to ensure that guidance is pertinent and appropriate. Service users physical and emotional needs are met and include access to physiotherapy, speech and language therapy, GP’s, community nurses and a range of other appropriate professionals. The medication systems and a random sample of medications were examined and found to be in order with the exception of handwritten additions to the Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 15 Medication Recording Sheets (MAR) needing to be double signed by the staff members involved in the transcribing of the dispensing instructions. No controlled drugs are held on the premises but systems and storage facilities are in place should this be necessary. Service users are encouraged and enabled to self-medicate where they wish and to support his their medication is accepted into the home and recorded by staff before service users sign for it. Service users have also been enabled and supported to take full control of their medication by going independently to the surgery, collecting the prescription and getting it dispensed. This is highly commended. All new medication is signed in and checked by staff. Returns are separately logged and returned to the pharmacist who signs acceptance for them. Staff have undergone training in the Advanced Care and Control of Medication and Infection Control training is now being provided. Medication is securely kept and the temperature of the room can be controlled. The temperatures of the refrigerator maintained for medication is recorded on a daily basis. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Neither of these standards were assessed. EVIDENCE: These standards will be assessed at the announced inspection. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 17 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): None of these standards were assessed. EVIDENCE: The key standards will be assessed at the announced inspection. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 18 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): 34. Service users are protected by robust recruitment procedures. EVIDENCE: Recruitment arrangements were checked and 4 staff files were examined. Criminal Record Bureau (CRB) checks are undertaken and a record is kept at the home. The certificate is retained at Head Office and these will be examined at the announced inspection. Two references are always obtained for new staff prior to them starting work. Photographs were not available on all the new staff files and the CRB number was not recorded. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 19 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): None of these standards were assessed. EVIDENCE: The key standards will be assessed at the announced inspection. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 20 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 3 3 X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 3 12 3 13 4 14 4 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 X X CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Percy Hedley Foundation Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000000331.V261449.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 9 Regulation YA13 Requirement The content of risk assessments must be reviewed. Risk assessments must be signed by the person carrying out the assessment. Risk assessments must reflect the supportive relationship and joint responsibilities of staff and service users. 2 34 YA18 Staff files must contain an up to date photograph and record of their criminal records bureau number. 07/01/06 Timescale for action 07/02/06 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 Refer to Standard YA5 YA6 YA20 Good Practice Recommendations Service users should sign the copy of their contact. Consider writing care plans in the first person. Ensure handwritten entries on medication administration DS0000000331.V261449.R01.S.doc Version 5.0 Page 22 Percy Hedley Foundation records are double signed by staff. Percy Hedley Foundation DS0000000331.V261449.R01.S.doc Version 5.0 Page 23 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.V261449.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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