Inspection on 14/04/05 for Hailey House

This inspection was carried out on 14th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Hailey House 07/08/08

Hailey House 13/06/07

Hailey House 13/07/06

Hailey House 06/10/05

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Hailey House Highlands Drive London Road Maldon, Essex CM9 6HY Lead Inspector Alan Thompson Unannounced 14th April 2005 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 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 Older People. 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. Hailey House Version 1.10 Page 3 SERVICE INFORMATION Name of service Hailey House Address Highlands Drive London Road Maldon Essex CM9 6HY 01621 854132 01621 842477 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Frank Stanley Kam Mrs Louise Kam Mrs S. Hibberd Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Hailey House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4th November 2004 Brief Description of the Service: Hailey House is a fully detached property, set in compact grounds in a wholly 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 two floors of the home. Access between levels is provided by stair lifts. Hailey House is a listed building and planning restrictions prohibit the installation of a shaft passenger lift. Communal space available comprises an L shaped lounge dining room with an adjoining conservatory style area at the far end of the lounge. Visitor car parking is available at the main entrance side of the property where there is also a small enclosed garden for services users use. At the rear of the home there is a small patio style area with seating. Hailey House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 1030 hours on Thursday 14th April 2005. Residents and staff were spoken with. Records, policies and procedures were inspected and a tour of the premises took place. All residents spoken to expressed satisfaction with the care they received and with the quality of the food and accommodation offered. Staff confirmed they received good support from management. What the service does well: 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hailey House Version 1.10 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Hailey House Version 1.10 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The home’s assessment format and process was adequate for ensuring that initial perceived needs were identified upon admission. EVIDENCE: The manager or deputy manager continue the practice of visiting prospective new residents prior to deciding whether Hailey House is suited to meet their needs. The assessment format used was seen and was unchanged since the last inspection. It contained headings including: communication, mental health needs, emotional needs, social needs, hobbies, vision, dental, hearing, sleep, bathing, mobility, washing, continence, dressing, diet, medication and a record of weight at time of admission. The manager confirmed that after admission these are re-assessed and a care plan is then compiled, although one care plan seen was incomplete. Hailey House Version 1.10 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 10 Individual care plans were in place however not all contained full information on daily actions required from staff. Care plans seen had not all been reviewed on a monthly basis. Residents said that staff treat them with respect, paying attention to their privacy and dignity when providing personal care support. EVIDENCE: The care plan format was unchanged since the last inspection. Care plans are compiled using the pre and post admission assessments carried out by staff, within approximately four weeks of admission. A sample were inspected and were seen to include information on the resident’s background information and history, details of family contacts, GP, a weight chart and a personal profile. Care plan headings show perceived daily needs for personal care, washing, dressing, bathing, toilet, eyes, mobility, nutrition, communication, social, emotional, and medical needs. The format included instructions for staff to follow with expected aims and outcomes, however one care plan file was not complete and did not contain this information. There is a requirement on this issue in this report. Hailey House Version 1.10 Page 9 Care plans inspected contained evidence of review by staff but not always to the monthly timescale recommended under the standard. Separate specific risk assessment sheets were included where appropriate, general risk assessments were kept separately. Also seen in care plan files were records of consultations/visits/occurrences. Residents spoken with confirmed that staff show full consideration to their privacy and dignity when providing personal care support. A telephone was available for residents, they were wearing their own clothes at the time of this inspection and the manager confirmed that medical examinations are always carried out in private. Screens were available for use in shared rooms. Hailey House Version 1.10 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The home caters for residents preferred choices of menu. Residents spoken with said they were satisfied with the food provided. EVIDENCE: The daily menu is displayed in the dining room. Nutrition records were inspected, the manager advised that menus were based on residents preferences and an alternative is always provided to those who do not like the main menu meal of the day. Specialist diets (eg: gluten free, diabetic) were also catered for. Teas are either hot or cold alternative. Drinks are provided at regular intervals and were available at all times. The manager confirmed that supper snacks were available, including sandwiches, cereals, however there were no residents in the home on the day of this inspection taking up this option. Staff provide appropriate support to residents at mealtimes. Food stocks were checked and were considered sufficient. Hailey House Version 1.10 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home’s complaints procedure allowed for residents and relatives to formally raise any issues or concerns. Residents said they felt they could speak directly with the manager if they had any issues about the care and services in the home. EVIDENCE: The complaints procedure was displayed in the home, this detailed who to complain too with timescales for expected response from the home. No complaints had been recorded since the last inspection but records had been maintained of past complaints received with written evidence of actions taken. Contact details of the local office of the registration authority were included. Hailey House Version 1.10 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 - 26 Hailey House is an established compact property and regular on-going maintenance is necessary. Individual and communal rooms seen were clean, acceptably decorated, warm and comfortable. Some communal areas were being used for wheelchair and hoist storage, the home would benefit from separate storage facilities for these items. This issue will be checked at the next inspection. Residents spoken with said they were satisfied with their rooms and with the facilities in the home. One resident had recently moved from a first floor room to a ground floor room at her request and she was pleased with the change. Hailey House Version 1.10 Page 13 EVIDENCE: The home is generally acceptably maintained throughout. Furnishings were considered comfortable and homely. The home employs two part time maintenance personnel. Communal sitting/dining space comprises one ‘L’ shaped lounge/dining room, with a conservatory type area at one end. There were three bathrooms available for residents, all provided fully assisted bathing facilities. The main use bathroom is on the ground floor this also provides seated shower facilities and a ‘spa’ bath. Residents bedrooms were inspected and were considered appropriately furnished in line with the standard and the individual wishes of residents accommodated. Many rooms contained personal possessions and the residents own items of furniture. Work has continued on fitting new low surface temperature radiators throughout the home. This work is on-going and will be kept under observation at future inspections until completed. Access to the laundry room is from inside the home. Since the last inspection new vinyl floor covering had been laid there which was now suitable for the area of use. Hailey House Version 1.10 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Staff numbers on duty at the time of this inspection met the required levels. Training records indicated that staff are provided opportunities to gain the skills relevant to their roles in the home. EVIDENCE: Staffing rotas evidenced minimum daytime staffing remains at four (including person in charge), on duty until 1500 hrs, reducing to three until 2030 hours. Night staffing is two on waking duties. Separate and additional staff were employed for cooking, cleaning, laundry and maintenance duties. The manager confirmed that no staff providing personal care support was under 18 years of age and that senior staff were all at least 21 years of age. Hailey House Version 1.10 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,36,37,38 The manager is qualified, competent and displayed commitment to providing a good service to residents. Staff were supervised but the frequency of staff supervision meetings needs to be increased. Staff training provided included the appropriate health and safety statutory and good practice subjects required. The manager was aware of the importance of ensuring that the home was safe for residents and staff. Hailey House Version 1.10 Page 16 EVIDENCE: The manager of the home is qualified and has been in post since 1994. She is a Registered Nurse and also holds the Certificate in Management qualification. At the time of this inspection she was awaiting clarification on the upgrade training modules required to achieve National Vocational Award level 4 certificates required of this standard. The manager has undertaken short course update training on subjects including collaborative care, abuse of the elderly & vulnerable people, manual handling, food hygiene and Parkinson’s disease. The manager’s job description had not been updated and still included out of date information regarding the manager’s responsibilities under care home legislation. There is a recommendation on this issue in this report. Lines of accountability in the home were clear and Person in Control reports were being completed satisfactorily. The home’s supervision format met the standard. The procedure includes a supervision agreement between the supervisor and supervisee, and a record sheet of issues included and discussed. Topics listed were: feedback from previous meeting, workload/priorities, professional development, training needs, personal and organisation issues. Evidence was still not available to confirm that timescales of meetings offered to staff met the recommended six times a year, there is a recommendation on this issue in this report. Random samples of records required to be kept were inspected. All were satisfactory except one care plan. Staff training records confirmed that training courses are provided in moving and handling, fire safety, medication, first aid, food hygiene and infection control. COSHH (Control of Substances Hazardous to Health) assessments are held in the home. Safety certificates were available for inspection to confirm that the home’s electrical installation supply, gas supply, fixed and portable hoists, stair lift, fire alarms & equipment and emergency lights have been tested by contractors. Portable electrical appliance testing is undertaken by designated staff. The hot water supply was regulated for delivery at or near a temperature of 43°C, (not tested). Risk assessments were in place for the premises and all assessed working practices. Hailey House Version 1.10 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x x x x 2 2 3 Hailey House Version 1.10 Page 18 No 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 7 Regulation 15 Requirement The registered manager must ensure that there is a written care plan in place for all residents. Timescale for action 30/4/05 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. Refer to Standard 31 Good Practice Recommendations The registered provider should ensure that the registered manager’s job description is updated to show current and not previous legislation by which the manager should work too. The registered manager should ensure that care staff are offered formal supervision at least six times a year. 2. 36 Hailey House Version 1.10 Page 19 Commission for Social Care Inspection Fairfax House Causton Road Colchester Essex, CO1 1RJ 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 Hailey House Version 1.10 Page 20 - 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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