Inspection on 06/10/05 for Hailey House

This inspection was carried out on 6th October 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 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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Hailey House Highlands Drive London Road Maldon Essex CM9 6HY Lead Inspector Alan Thompson Draft Report Unannounced Inspection 6th & 19th October 2005 11:15 X10015.doc Version 1.40 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 Hailey House DS0000017840.V254048.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 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 DS0000017840.V254048.R01.S.doc Version 5.0 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 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) Mr Frank Stanley Churchill Kam Mrs Susan Jane Hibberd Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 22 persons) 14th April 2005 Date of last inspection 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 DS0000017840.V254048.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 1115 hours on Thursday 6th October 2005. This was the second inspection of this home in the inspection year 2005/6. The inspector made an arranged return visit to the home on Wednesday 19th October 2005 to speak with residents. This second visit was only made as many residents were busy and were not able to speak with the inspector on 6th October. The content of this report reflects the inspector’s findings on the day/s of the inspection, and from taking account of relevant findings from previous inspections of the home. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Residents, visitors and staff were spoken with. Random samples of 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. Visitors spoken with confirmed that they considered the home provided a good care service to residents. Staff confirmed they received support from management. They also confirmed that they had been offered NVQ training. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home’s quality assurance process needs to be implemented. Some residents would benefit from organised activities being offered more frequently. -------------------- 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. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 8 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 the following 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 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. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 8&9 The health care needs of residents were generally assured. The home’s medication procedures, practices and staff training appeared to provide adequate guidance for dealing with medicines. EVIDENCE: Care plans were in place for all residents and contained daily actions required from staff. In-house reviews had taken place. Local dental services have been difficult to arrange as practices in Maldon have not been accepting NHS patients. Domiciliary dental services are also very difficult to find. An NHS community chiropodist is available (waiting list applies) although this service may be reviewed by the local NHS trust. Private chiropody can be arranged. District nursing services support the home in providing for specific nursing needs, including pressure sore treatment and provision of equipment and aids. District nurses also currently provide continence issues guidance/advice. Hearing tests and nutritional advice is accessed from a local hospital after referral from the GP. Optician services visit the home annually. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 10 Residents are registered with one of the home’s two GP practices (unless they are able to keep their own GP). One practice will visit the home weekly if required. Emergency visits are available at all times. The home’s written policy and procedure on medication practices contains guidance for staff on ordering, storage, administering and returns of unused medication. Also included was the home’s policy and procedures regarding residents’ who wish to retain responsibility for administering their own medication. Administration records were inspected and were found to be appropriately maintained. The manager confirmed that she only allows staff she has judged as competent, to administer medication. A record sheet is completed to evidence testing has taken place for any new staff taking on this role, although generally staff administering medication are long serving and have been undertaking this task for some time. All staff administering medication have received certificated training entitled ‘Safe Handling of Medicines’. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 12, 13 & 14 The home appeared to have maintained good contact with, and encouraged involvement from relatives and friends in the community. Residents were supported in exercising choice regarding day to day routines in the home. Varied activities were available, although an increase in the frequency of organised recreational activities would benefit some residents. EVIDENCE: An activities person works in the home two afternoons each week for 2 hours. Records had been kept of activities offered to residents, these included: reading, darts, bean bags through hoops, questionnaires, poems, quizzes, singalongs & hoopla. Comments from some residents and visitors indicated that they would like the option of more frequent daily activities. A church service is held in the home every four weeks and one resident still sometimes attends church outside the home. One resident still attends a community based club. The manager confirmed that flexibility is available at mealtimes. Residents may eat in their rooms if they wish, and some said they did. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 12 Visitors are welcome at all reasonable times. The statement of purpose states that an ‘open’ visiting policy applies. Residents & visitors spoken with said they were made welcome by staff. There is a small room available for privacy if required, although this is also used at times as the hairdressing room and for some storage. Privacy screens were seen in shared bedrooms. The manager confirmed that staff would respect residents’ wishes about whom they see and do not see. Community contacts include (in addition to regular church services) occasional visits by local school children, a ‘pat the dog’ visiting service, a weekly hairdresser and three weekly visits from the mobile library service. Independent advocacy services are available. A new scheme on offer is from an organisation called ‘Care Aware’, the manager will soon be displaying information leaflets regarding this in the home. Residents meetings take place, minutes were seen. Issues discussed included food, activities, complaints. Relatives have been invited to these. Residents personal finances were all dealt with by relatives, although the home did keep personal cash for safe keeping for some. Records were maintained. Records of personal possessions brought in on admission were included in care plan files. The home’s Data Protection statement was included in the terms and conditions of residency document. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 18 Procedures and polices in place were aimed at protecting residents from abuse. EVIDENCE: The home has a comprehensive policy and guidance document for staff on dealing with suspected or alleged abuse, including a practical guide on who to notify. The policy also details expectations regarding accurate recording of incidents or allegations. There is a detailed ‘whistleblowing’ policy document giving clear guidance on staffs’ responsibilities under this heading. The manager has obtained a training package entitled ‘Abuse in Care Homes’ which is accessed by staff. Staff have also received training on the POVA (protection of vulnerable adults) procedures. The full DOH guidance document on POVA was left at the home by the inspector. The manager has contacted the Essex Vulnerable Adult Protection Committee and issued their guidance booklet to all staff. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 19–21, 23-26. The home was generally comfortable and adequately maintained. Residents’ outdoor space was accessible, but was very compact. The premises appeared safe and had sufficient (according to these standards) numbers of toilets and bathrooms. The home was considered clean and hygienic. Storage space is very limited. EVIDENCE: Hailey House is an established compact property and regular on-going maintenance is necessary. The home employs two part time maintenance personnel and work was going on the day of the inspection. Individual and communal rooms seen were clean, acceptably decorated, warm and comfortable. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 15 Some communal areas were still being used for wheelchair and hoist storage, the home would benefit from separate storage facilities for these items. Residents spoken with said they were satisfied with their rooms and with the facilities in the home. 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 on fitting new low surface temperature radiators throughout the home has been finalised. Access to the laundry room is from inside the home. This is an ‘add-on’ timber building but was considered fit for purpose. Equipment met the standard. The inspector understands that the local fire service have inspected this building. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 16 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 Staff recruitment procedures aimed at the protection of residents had been followed. Staff were provided induction and training opportunities to ensure competency in undertaking their roles. EVIDENCE: Staff recruitment records evidenced that application forms were completed, interviews were held and notes kept, two references obtained, criminal records bureau checks undertaken and proof of ID and photograph kept. Contracts of conditions of service and job descriptions were issued to new staff. Copies of training certificates were also kept on staff files. Training needs for new staff had been recorded. The six week induction of new staff is provided over four modules covering: principles of care, records, fire & security, moving & handling, health & safety, risk assessment, infection control, food handling, care of residents, practical care skills, care & use of equipment, care of dying, needs of residents, specific disabilities, activities & stimulation. A record of progress and completion of this training is maintained, this includes questionnaire sheets to evidence competency and understanding. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 17 The foundation pack is worked over five modules, these cover: empowerment, achievement, fulfilment, recognising constraints, anti discrimination, communication, physical contact, barriers & challenges, record keeping, health & safety, worker development, nature of abuse, nature of neglect, signs & symptoms of abuse & neglect, how and when to respond to abuse, needs of the individual and person centred services. Staff training records recorded that manual handling, first aid, health & safety, food hygiene, medication, POVA, fire awareness and NVQ training had been provided to staff. Infection control training is due. NVQ training has progressed and five carers were undertaking the NVQ 2 award, two already had the level 2, one had the level 3 and two were undertaking level 3. The manager is a qualified nurse and holds the DMS (Diploma in Management Studies award). Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 18 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 & 37. Procedures for gaining the views of residents and relatives had not been implemented. Residents’ financial interests appeared to have been safeguarded. Records required by regulation were in place and up to date. EVIDENCE: The quality assurance questionnaire in place is a comprehensive eight page document asking for views/ comments on the environment, activities & entertainment, also included is food and choices available. A shortened one page version is also available for residents who do not wish to complete the full questionnaire. Unfortunately neither process had been implemented in the past 12 months. There is a requirement on this in this report. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 19 The manager has invited relatives to a residents’ meeting in the home, with their agreement, and there is still a suggestion box in the main entrance hallway. There were no residents managing their own financial affairs. Relatives or the Court of Protection provided this support. Personal allowance monies were held for safekeeping for some residents. Records were maintained of balances and transactions. A random check of these was made. No errors were found. Records of personal items brought into the home on admission were recorded in care plane files. Random samples of records required to be kept were inspected including: Staff recruitment, staff rota, visitors book, regulation 37 notices, money held for safekeeping and fire procedures. Evidence was available to confirm that the frequency of individual staff supervision meetings has improved. The registered provider was updating the managers job description, however the final version was not yet available, therefore the recommendation on this issue made in the last report remains active in this report. Hailey House DS0000017840.V254048.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X 3 X Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 21 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. 1 Standard OP33 Regulation 35 Requirement The registered manager must ensure that the home’s quality assurance process is implemented, with records available for inspection. Timescale for action 31/01/06 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 Refer to Standard OP12 OP31 Good Practice Recommendations The registered provider should ensure that activities in the home meet residents’ expectations. The registered provider should ensure that the registered manager’s job description is updated to show current not previous legislation by which the manager should work too. Hailey House DS0000017840.V254048.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, 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 DS0000017840.V254048.R01.S.doc Version 5.0 Page 23 - 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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