Inspection on 27/05/10 for Hailey House

This is the latest available inspection report for this service, carried out on 27th May 2010.

CQC found this care home to be providing an Good service.

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

Hailey House 13/06/07

Hailey House 13/07/06

Hailey House 06/10/05

Hailey House 14/04/05

Hailey House 04/11/04

Hailey House 20/05/04

Hailey House 28/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 03/09/2010.

Random inspection report Care homes for older people Name: Address: Hailey House Highlands Drive London Road Maldon Essex CM9 6HY two star good service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Diane Roberts Date: 2 7 0 5 2 0 1 0 Information about the care home Name of care home: Address: Hailey House Highlands Drive London Road Maldon Essex CM9 6HY 01621854132 01621842477 haileyhouse@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Susan Jane Hibberd Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Frank Stanley Churchill Kam care home 22 Number of places (if applicable): Under 65 Over 65 22 old age, not falling within any other category Conditions of registration: 0 Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 22 persons) Date of last inspection Brief description of the care home Hailey House is a fully detached property, set in compact grounds in a residential area, approximately a quarter mile from the centre of Maldon. The home is registered to accommodate twenty-two elderly people over the age of 65. Accommodation is provided in 14 single and 4-shared rooms on all three levels of the home. Access between levels is provided by stair lifts. Hailey House is a listed building and planning restrictions, in the past, have prohibited the installation of a shaft passenger lift. The Care Homes for Older People Page 2 of 9 Brief description of the care home proprietor has overcome this and plans are in place to extend the home and install a passenger lift. Communal space available comprises an L shaped loungedining room with an adjoining conservatory style area at the far end of the lounge. Visitor car parking is available at the main entrance of the property where there is also a small, enclosed garden for residents use. At the rear of the home there is a small patio style area with seating. Fees for the home range betweenGBP415.00 and GBP507.00 weekly depending on the accommodation provided and the dependency of the resident. Care Homes for Older People Page 3 of 9 What we found: When we arrived, residents were seen to be relaxing and reading the papers in the lounges and their own rooms. They had drinks available to them and the lounge was seen to be homely and comfortable. Two care plans were reviewed at random. Overall the care plans had improved since our last visit, but there are still some areas for work. The care plans in place were seen to generally detailed and person centred. Dates were not evident on the care plans so it was not apparent how up to date they were in relation to the assessment of need and this should be addressed. Residents have monthly report reviews completed and these give a good overview and occasionally identify that the care plan has been updated. In some cases when we checked the care plan had not been updated. The reviewing system needs to be more robust. Risk assessments are in place for a range of items but again the evidence of review was inconsistent. The manager confirmed that no residents have developed home acquired pressure sores in the last year. Daily notes completed by staff evidence the level of care support needed and that staff are good at meeting residents emotional needs and communicating with relatives. Records also evidence a proactive approach to residents health care needs and good links with the visiting doctors. Again the team at the home need to have a more robust system in place for the nutritional monitoring of residents. This was raised at the last inspection in 2008. Residents who cannot stand on the scales are assessed using a BMI score, which is not always accurate and it is very time consuming for staff to carry out. It is not completed on a monthly basis. It is also apparent from the records that residents are not always weighed, even when possible, on admission to obtain a baseline reading. Parts of the MUST nutritional assessment tool are used to record weights but again this is inconsistent and does not constitute a full nutritional risk assessment. The team at the home do not have access to sit on scales. Since we last visited the home the manager now has proper storage for controlled medications and the correct record book in which to record them. The manager confirms that items are now no longer left with residents for them to take later. The manager does not complete a medication audit and as part of good practice and quality assurance we would recommend that one is developed. Social care plans are in place and these primarily contain preferences and some good information on daily choices that residents do or may make. Social profiles, which give some good person centred information are also in place. More could be done on assessing what residents may actually need in relation to social care that may help them, for example, maintain independence and skills. The complaints procedure is available in the main reception area. It requires updating to show that people can raise concerns with their referring authority if they wish or if it is appropriate for them. Since we were last at the home the manager has improved the recording of concerns and complains and now makes a record of all issues, however minor raised with her and what has been done about them. Overall the concerns were minor, for example, the shape of the sandwiches made and doors being left open, but the approach of the manager is sound and objective. Care Homes for Older People Page 4 of 9 Since we last visited the home the corridor lighting has been enhanced throughout the home, giving a better level of light in the darker corridors. The floor has also been fixed in the upstairs corridor and there is now no tripping hazard. Bedrooms are decorated on an ongoing basis and there has been some carpet replacement in some of the bedrooms. The maintenance man is currently making good some of the walls where cables etc have been run for the new lighting. The home was seen to be clean, no odours were noted and it is generally well maintained. Some areas are untidy and the staff team need to address this in relation to wheelchair storage and items left in bathrooms etc. We reviewed fire safety records and found that the fire safety risk assessment, which was completed in 2008, has not been reviewed. As things change in homes, this should be undertaken yearly. The manager also needs to undertake more staff fire drills as the last one was August 2009. The alarm system is tested weekly but the emergency lighting is not tested regularly to see if it is working. The maintenance man undertakes the fire safety training in the home, having been trained as a trainer himself. The manager was not aware when he needs to retrained or be updated to continue undertaking this role. The manager needs to take a more robust approach to fire safety. The home has a low staff turnover and has only four hours vacant, which are covered by the current staff team. The current staffing levels, based upon the dependency of residents is 4 care staff in the morning, 3 in the afternoon plus ancillary help with the evening meal and 2 staff at night. The manager works 5 day a week and has a very hands on approach. Whilst it is good for managers to know what it is like on the floor, a balance needs to be made with her management responsibilities to ensure that the home is managed well and continues to develop. Staff files were checked at random and showed that the recruitment of staff is robust with all the required checks and documentation in place. The staff training matrix shows that overall compliance with statutory training is good in all subjects and that some staff have also attended additional training on dementia last year. Other than this additional training on, for example, conditions associated with old age etc, has been minimal since 2008. We saw evidence that staff were up to date with training and this included evidence of questionnaires that they had completed, for example, in relation to adult protection. Records submitted show that only 6 of the staff have achieved NVQ qualifications and 3 plan to do this. The team have not reached the desired 50 level. The manager is planning to provide staff training on nutrition and has a DVD to facilitate this. We would recommend that this is pursued. The manager has regular meetings with residents and asks them to complete feedback sheets, the last ones being done in November. The residents at the home are very vocal and participate in discussions, it is a shame that the manager has not analysed the results of her feedback and developed an action plan for issues/areas for development/review. Minutes of residents meetings show that the residents are happy living at the home, they feel well cared for and think that the staff treat them well. This is echoed in the surveys that we had returned to us from residents. Comments are variable with regard to the food and there is an ongoing process where residents comment and meals and choices are changed in an effort to please the majority of people. Residents are consulted on all aspects of their life in the home and the minutes show that staff make suggestions for residents to consider. Residents feel safe in the home and know who to speak to if they have any concerns or complaints and again this was echoed in the surveys we received back from residents. From discussion with the manager and minutes Care Homes for Older People Page 5 of 9 of residents meetings, it is clear that the residents often decide between themselves about things that affect their daily routine. The recently have decided to have the television turned off for a bit during the afternoon and often look at the timing of when they would like to take meals. The manager has also surveyed relatives who comment positively on the home, for example, happy homely environment and very happy. Relatives said that they felt welcome at the home and all would recommend the home. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 6 of 9 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 7 of 9 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 12 Residents nutritional status 16/08/2010 and weight must be monitored regularly and their care needs managed accordingly. So that residents health care needs are met in full 2 19 23 Adequate precautions must be taken against the risk of fire. So that residents, staff are visitors are protected as far as possible. 31/07/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 3 4 7 9 16 30 Record dates on all care planning/management records. Develop a medication auditing system. Update the complaints procedure. Give consideration to providing staff training on conditions associated with old age. 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