Inspection on 07/08/08 for Hailey House

This inspection was carried out on 7th August 2008.

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

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 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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Hailey House Highlands Drive London Road Maldon Essex CM9 6HY Lead Inspector Diane Roberts Unannounced Inspection 7th August 2008 09:30 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.V369674.R02.S.doc Version 5.2 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.V369674.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hailey House Address Highlands Drive London Road Maldon Essex CM9 6HY 01621 854132 01621 842477 haileyhouse@hotmail.co.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) 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.V369674.R02.S.doc Version 5.2 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) 13th June 2007 Date of last inspection Brief Description of the Service: 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 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 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 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 between £415.00 and £507.00 weekly depending on the accommodation provided and the dependency of the resident. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The unannounced site visit was undertaken over a seven-hour period by one inspector as part of the routine key inspection of Hailey House. Time was spent talking with the residents, staff and a visiting GP during the day. A tour of the premises was undertaken and records and policies were sampled. The manager was available throughout the day and assisted us with the inspection. The manager submitted an Annual Quality Assurance Assessment prior to the site visit. This details their assessment of what they do well, what could be done better and what needs improving. This information was considered as part of the inspection process and is reflected as part of the report. Prior to the site visit, the manager was sent a variety of surveys to distribute and that asked questions that were relevant for each group, such as for residents, relatives, staff, care managers and healthcare professionals. Responses were received from three residents and their comments and responses are reflected throughout the report. The outcomes of the site visit were discussed with the manager throughout the day and during feedback at the end of the inspection, where opportunity was given for clarification where necessary. What the service does well: The residents’ benefit from having a stable staff group to care for them, with whom they have good relationships providing a friendly and homely atmosphere. Staff are very resident led and the care provided is individualised. Both permanent and respite residents are happy at the home and comments include ‘ I would come back to this home’, ‘I was surprised at the nice atmosphere in the home and the caring approach’ and ‘ the staff are lovely and do not rush you’. Staff at the home listen to residents and deal with their concerns well and act, wherever possible, to improve any issues. The meals service at the home is also good and residents are generally very happy with the food. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 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.V369674.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that their needs will be assessed prior to admission and that they will be helped to settle quickly in to the home. EVIDENCE: A service user’s guide is available for residents and this is to become part of the new welcome pack, being developed by the management team at the home, as outlined in the manager’s AQAA. There are plans to implement this soon, as the manager confirmed that the pack is currently with the printer. The service user guide was reviewed and on discussion with the manager, it was agreed that the format was not very user friendly, due to the size of the print, general layout and context – it not fully being written for the resident. It was also noted that some information, as required by regulation, is missing. It is recommended that the service user guide be reviewed to address the shortfalls noted and provide a more user-friendly version for residents. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 9 Recently admitted residents confirmed that they had seen the guide and had also had a brochure, but the guide was with their families and no longer in the home with them. The manager states in the AQAA that the home now has a dedicated website in order to provide more information on the home. The manager has a pre-admission assessment system in place. Two recent assessments were reviewed. The recording documentation was fully completed and backed up by information, where appropriate, from social services. It was also evident from the records that relatives had participated in the process where possible. The assessment documentation requires review and updating. The form is needs led and would benefit from providing the staff team with more person centred and social information. It was noted that the deputy manager, who assesses prospective residents along with the manager, had been recording such information on scraps of paper, which may be mislaid and therefore lost to staff. Prospective residents are encouraged to visit the home and residents spoken to confirm that they or their family had visited the home prior to admission. Residents spoken with regarding their admission to the home were very happy with the process and how the staff team had helped them settle in. Comments included ‘ When I came in, the staff helped me to settle in along with my family – I was made to feel at home’, ‘I would come back to this home’, ‘I was surprised at the nice atmosphere in the home and the caring approach, I was not expecting it – it was a nice surprise – a smaller home makes all the difference and ‘some of my friends commiserate with me (for living in a care home) but they really do don’t have to – I have been here (x) months and I really feel at home. The manager states in her AQAA under ‘What they do well’, ‘ Residents settle in quickly’. This concurs with the feedback from residents. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that they would receive a good standard of individualised care at the home. EVIDENCE: The manager has a care planning system in place and three care plans were reviewed at this inspection. Overall the care plans were good, with an individualised approach to the care to be provided. Detailed preferences and person centred information was available. Care plans were seen to be up to date and each resident’s key worker also completes an informative review. It would be valuable to ensure that important comments outlined in the key workers review are transferred into the actual care plan, where appropriate, and a review of the documentation format may aid this. This was discussed with the manager, who in her AQAA states that ‘ they would do better with the reviews being key worker led’. Residents spoken to at the home were not aware of their care plans themselves but were aware that their relatives had been involved with them. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 11 The manager regularly admits residents for respite care and whilst care planning information was seen to be in place one respite resident did not have a full care plan, however the manager evidenced recent respite admissions that did have them and stated that this was an oversight due to key staff being on annual leave. The care plans could be further improved by ensuring that all areas of a person needs have a care plan and this particularly relates to emotional support and pain relief, which were not all in place, where needed, although staff demonstrated an understanding of the needs of the resident. Residents generally had appropriate risk assessments in place, for manual handling and personal risks etc. These could be improved upon by having them completed in a timely manner for respite residents and were seen to need more detailed information so that staff could be clear about the risks. The manager, who does not have any sit on scales, uses a nutritional assessment tool for all residents and this was seen to be maintained up to date. Some residents are able to use a stand on set of scales and others have to have their weight assessed. This is not ideal and the manager appreciates this. Records showed that the residents are seen by their GP in a timely manner, when the need arises. A visiting GP to the home concurred with this and said that they are called appropriately to the home and felt that the standards of care at the home were very good. Records also showed that residents have access to other visiting healthcare professionals such as opticians and chiropodist etc. Residents who were observed to have sensory impairments had equipment available to help them maintain daily living activities. Residents comments included ‘ I was in X home for a while and there is no comparison – this home is far superior’, the staff do not rush anybody’ and ‘staff come quickly if you use the call bell’. Residents who completed the manager’s recent satisfaction questionnaire, all commented that ‘they felt well cared for’. The medication system was inspected and found to be maintained in a satisfactory order. The manager plans to move over to a different supplier soon to improve support and training to the home. Information was seen to be available for staff on the use of ‘as required’ medications and this is helpful. As stated in the manager’s AQAA monitoring/audit sheets have been used, with the last one being completed in June 2008. Recording on the medication records was good and medications are generally checked in properly, although staff need to ensure that additional medications started during the month are also checked in. Controlled medications were checked and found to be correct. The manager needs to ensure that she is using the correct recording method, i.e. a numbered loose-leaf system rather than a standard bound book. There are two areas that need addressing. The drugs fridge was not having the temperature monitored, this needs to be done to ensure medications are stored at the correct temperature. It was also noted that, whilst trying to meet residents individual needs, medicines were being left with residents so they could take them at a later date and then being signed for by a member of staff, who did not witness them taking at as they Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 12 were not on duty at the time. This needs to be reviewed, discussed with the residents concerned and a more responsible procedure adopted. Medication left unattended and possible untaken is a potential risk. This was discussed with the manager. Training records show that the medication training for some staff is a little out of date and hopefully this will be addressed with the manager’s planned change of supplier. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can generally be assured that their individual needs will be met but outcomes could be better with regard to activities. EVIDENCE: From discussion with the staff, residents and from the care plans, it is clear that routines in the home are generally resident led. Resident comments included ‘there are no restrictions – you are not bundled off to bed at 06.30 p.m, I go when I want’ and I spend my time how I wish’. In some areas of care planning, more work could be done on resident’s preferences on daily routines as, for example, residents are taken tea at 06.00 a.m and from discussion, this is not to everyone’s choice. However there is equally good evidence of individual care from discussion with residents, staff and review of the records. Staff comments included ‘ we try to get people up when they want to get up’, ‘ we do breakfasts, some residents eat early and others eat later, it depends whether the resident is having a lie in, no day is the same’ and ‘we do what they want, its not up to us’. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 14 A lady visits the home twice a week to undertake activities with residents. In addition to this staff do undertake impromptu activities that include dancing and music. Since the last inspection, more effort has been made to take residents out of the home and records show that this is happening. The manager, in her AQAA, states that ‘ we are planning a rota system for taking residents out’. Records evidence that this has happened and is still developing. Recently residents have been taking into the town for shopping, attended the local carnival and 8 residents went to a concert at a local school. Activities records are maintained and these show the activity offered and whether a resident has chosen to take part or not. Activities included quizzes, bible stories, reading out loud, throwing balls, raffles and craft. Activities are not necessarily linked to individual preferences and this could be developed, by linking in with a social care plan. Residents who commented on the activities said ‘that a lady comes in and plays a game and reads and they have a nice TV’ and ‘a lady comes in an does games, catching balls and reads a book to us, but its not my thing even though she is a worthy lady, its limited’. Some residents are very social and were observed to be enjoying playing dominoes in a group, which they do most afternoons after lunch. The manager, in her AQAA states what we need to do is ‘Extend the individual activity care plan to incorporate more information about their past activities so they can be included or adapted for their present needs’ and ‘ to replace seated exercise instructor as previous one left. Extend care plans for activities’. Staff spoken to felt that the activities in the home ‘could be so much more’. Since the last inspection the manager has reviewed the menus and has increased the amount of fruit and vegetables available and has increased the choice available at teatime. Records show that residents are making choices and having alternatives. Whilst there is still one choice for the main meal all residents spoken to say that they could have an alternative if they wished. They said that ‘ the staff go round every morning and tell everyone what is for lunch and if you want something else you say then’. The manager in her AQAA plans to extend choice further and states under how we could improve, ‘to complete introducing more of a choice of menu at lunchtime’. Residents were complimentary regarding the food and comments included ‘ its normal everyday food that families eat, its hot and tasty’, the food is very good, but not enough choice’, ‘ wonderful on cakes, every afternoon, always homemade – very good ones’ and ‘the food is good’. Tables were seen to be nicely laid, with cloth napkins and flowers. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that their concerns would be listened to and taken seriously and that they would be protected as far as possible. EVIDENCE: The manager has a complaints procedure in place, which is displayed in the main hallway. It also needs to be available, in full, in the service users guide. Residents spoken to were clear that they know who to raise any concerns with and felt comfortable doing so. Residents spoken to say that ‘ they would raise any concerns with the manager, who is very nice’ and ‘I would raise any concerns with the person in charge and have no reservation about this’. Since the last inspection the manager has improved her recording of complaints to include any minor verbal complaints, to enable her to use the records to improve the service. All records were reviewed and were seen to be very good, with objective, appropriate outcomes and dealt with in a timely manner. The Manager, in her AQAA states that ‘Any complaints are logged and dealt with within 28 days. Most complaints are minor and can be dealt with straight away. Any concerns are passed on to staff via handover’. All complaint records seen were minor and related to the day-to-day running of the home. No formal complaints have been received. In her AQAA the manager states under what they could do better is ‘To keep reminding staff to log complaints however minor. Complaints being logged, staff starting to understand complaints can be used to improve service’. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 16 The manager keeps a record of compliments from relatives and these included ‘staff show great compassion and kindness and provide dignity’, ‘ The treatment of my relative was exemplary’ and ‘There could have been no better choice for my relative’. The manager has an adult protection policy in place but did not have a copy of the recently updated local guidance from Social Services. It was recommended that a copy be obtained for the most up to date information. Since the last inspection, more staff training on adult protection has been provided and training records show that all staff have had training and that further training is planned this month and evidence was available of the booking. On discussion with staff they were knowledgeable about what they should do if they suspected abuse but were unaware of the role of social services. Obtaining local guidance may help with this. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment meets the needs of the residents in the home and generally ensures their safety. EVIDENCE: A partial tour of the home was undertaken with the manager. Hailey House has a homely environment and is very welcoming. Pictures and ornaments are displayed in the communal areas and residents spoken to comment positively on the environment. Since the last inspection the bathroom refurbishments have been completed, some bedrooms have been decorated and some carpets replaced. One double has been turned into a single room with an ensuite and additional lighting has been installed in some corridors. The lounge has been redecorated and new table linen is on order. Work has also been undertaken to update the wiring of the home, smoke detectors and a new boiler has been installed. It is clear on touring the home that work has been undertaken although there is still Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 18 snagging to do in the lounge and the entrance hallway. Some areas of the home still require work and this includes the upstairs carpet and in some areas, floorboards. It was evidence that the floorboards underneath the carpet had deteriorated in one area and required attention, as the floor was dipping creating a tripping hazard. This was discussed with the manager. The proprietor has plans to extend the home to provide more single rooms with ensuites and if possible a passenger lift to replace the current stair lifts. Residents spoken to were happy with the accommodation and cleanliness of the home. They confirmed that they had been encouraged to bring their own personal items. Their comments included ‘ I have everything I want in my room’, ‘I have a nice room and I can see the trees and the sky’ and ‘I am very comfortable and I have some of my own furniture’. The manager has recently updated the home’s fire safety risk assessment and fire safety records show that regular checks are undertaken along with the professional maintenance of equipment. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from an experienced and stable staff team who are trained to meet their needs. EVIDENCE: The manager states that she staffs the home according to residents’ dependency, although at the current time she has no formal tool to assess this. Current staffing levels are 3 in the morning, 3 in the afternoon/evening and 2 awake at night. From discussion with the manager and staff, increases have been made in staffing levels since the last inspection and often in the mornings a care support worker is also on duty, who does not provide personal care, but assists with other duties such as breakfasts and bed making etc. This has helped the care staff team but on discussion with them, they feel that they need this input every day. The manager reports that if required, staff can and do stay longer if residents’ needs dictate. Agency staff have been used over the past few months to cover maternity and sick leave. The rotas reviewed reflect the information given by the manager. The manager tries to ensure consistent agency staff to cover shifts so they get to know the residents. Residents spoken to did not highlight the use of agency staff as an issue to them. Residents spoken to commented positively on the staff team and comments included ‘they are lovely, no rushing anybody and if you want anything they help’, ‘the staff team are fine, polite, just like members of the family’ and ‘ The staff couldn’t be kinder’. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 20 From records, 35 of care staff working at the home have achieved an NVQ qualification in care. From discussion with staff there are a percentage of long term staff at the home who do not wish to take up this training and others who do, who are over 25, are having difficulty in funding. This is affecting the manager’s ability to achieve the desired levels. From the manager’s AQAA, staff turnover at the home is low. The manager’s recruitment process was reviewed and found to be in good order. Two staff files were reviewed, from new staff, and these contained all the required checks and documentation, including criminal record bureau checks. The manager uses a checklist system to ensure all requirements are in place and there was good evidence that acceptable references had been pursued. The manager maintains a staff training plan/matrix and staff spoken to at the home confirmed the staff training that they had completed in the last year, which included adult protection, fire safety, dementia, infection control and manual handling. The manager in her AQAA states ‘Training is taking place in dementia (even though we are not registered) to help staff be aware of changing mental states and how to deal with it.’ This is a positive and proactive approach and records show that 8 staff have attended this training. The training matrix shows that there is good compliance with adult protection, fire safety and manual handling, health and safety and infection control training. There are notable gaps in medication training. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the home is run in their best interests. EVIDENCE: The manager has been working at the home for 12 years. She is a qualified nurse and is thought highly of by her staff and the residents, who find her approachable. From the training matrix, the manager does need to ensure that she keeps herself up to date with current training as she also works hands on, at times, in the home as well as in her role as manager and also to help monitor practice and quality in the home. Some systems in the home would benefit from being more organised to assist the manager in the smooth running of the home The manager holds staff meetings and minutes of these were available for inspection. Meetings cover a range of subjects, updating staff on changes in Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 22 the home and reminding them of good practice and thanking them for their help. Resident meetings are also held and these are well attended and the minutes show that residents feel free to raise a variety of subjects and opinions, on such subjects as the setting out of the lounge area to the menus. Since the last inspection, as outlined in the manager’s AQAA, she has introduced a new suggestion box in the hallway for all interested parties. The manager undertakes a variety of general audits in the home, relating to medication, staff files and the meal service. A key part of the quality assurance systems in the home is the feedback that the manager seeks from residents and relatives. The manager was currently undertaking this audit at the time of the inspection but was able to let us see the most recent feedback. The manager also had evidence from her last resident audit, which showed that she had reviewed the results, undertaken an action plan and written to interested parties with the results. This is good practice. Recent feedback from 6 residents was seen and comments were positive with residents happy with the home, they felt safe and only really had positive suggestions for changes to the menu. When asked ‘do you like living here?’ residents responded with ‘yes, love it’ and ‘yes wonderful’. When asked whether the staff treated them well all of the respondents answered ‘yes’. The manager only holds a small amount of personal monies on behalf of residents, with families and advocates being encouraged to take the lead on this. The manager hold a small amount of petty cash should anyone need anything or wish to go out. Systems have not changed since the last inspection and remain in good order. Since the last inspection the manager has improved the staff supervision system and this is now cascaded down through the senior members of staff so they all take a role. Supervision records were available and staff spoken to confirm that they had supervision and that it was within appropriate timescales. The manager plans to develop observation supervision as part of the system, in line with local authority contractual requirements. The manager keeps accidents records and these were available for inspection. Cross checking with care plans records and from discussion with the manager there is good evidence of follow up on any falls etc. The manager is unaware of any falls prevention team in the area and was advise to research this as it could be a valuable resource to residents in the home. From the training matrix, it is positive to see that all staff have completed health and safety training in the past two years. Kitchen staff hold current food hygiene certificates and 15 of care staff also have had training in this subject. A random check of maintenance and safety certificates for fixtures and equipment in the home were up to date in good order. This concurs with the information given by the manager in her AQAA. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 23 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 2 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Residents need to have care plans and risk assessments in place that address all their care needs, with particular reference to emotional support and pain relief. This helps to ensure that their needs will be met in full. Medication must be stored and given according to safe procedure to ensure that all residents in the home are protected. The damage to the floor upstairs needs to be addressed to reduce the risks of falls to residents walking in this area. Timescale for action 30/09/08 2. OP9 13(2) 30/09/08 3. OP19 23(2) 30/09/08 Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 25 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. 5. Refer to Standard OP1 OP8 OP12 OP18 OP27 Good Practice Recommendations The service users guide needs a review to ensure it is in an appropriate format, the right context and that it contains all the required information. Consideration should be given to purchasing a set of sit on scales so that residents’ nutritional needs can be more accurately assessed. Where possible, activities should be tailored to each person’s assessed needs and preferences. The manager should obtain a copy of the local authority safeguarding procedures and make these available to staff. The manager should formalise her dependency rating of residents to help her monitor and adjust staffing levels as required. Hailey House DS0000017840.V369674.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V369674.R02.S.doc Version 5.2 Page 27 - 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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