Inspection on 30/08/07 for The Hailey

This inspection was carried out on 30th August 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Hailey 06/07/06

The Hailey 20/02/06

The Hailey 08/08/05

The Hailey 25/08/04

The Hailey 14/04/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Hailey 7/8 The Downs Herne Bay Kent CT6 6AU Lead Inspector Mary Cochrane Unannounced Inspection 30 August 2007 09:30 th The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 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 The Hailey DS0000058573.V345760.R01.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hailey Address 7/8 The Downs Herne Bay Kent CT6 6AU 01227 742366 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) allaboutcare@btconnect.com All About Care Ltd Post Vacant Care Home 33 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (7) The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Hailey looks out over The Downs and out to sea. It is only a short distance from Herne Bay’s town centre and so offers ready access to a range of community based facilities. The main part of the premises is two older two-storey properties, which have been joined together and adapted for their present use. The accommodation for clients is arranged on each of the floors. On the ground floor there are various lounges and other communal areas. The first and second floors are used for service users bedrooms and there are also toilets and bathrooms on these levels. To the rear of the main buildings, there is a suite of purpose built bedrooms. When the Home is full, there is provision for two of the bedrooms to be shared. The remaining bedrooms all offer single occupancy. All of the bedrooms have a wash hand basin, with those in the new build section having a full en-suite service. The newly built bedrooms form a quadrangle with the main building. This is a popular area with the service users because it is out of doors while at the same time being private. To one side of the site, there is also a more conventional garden area. The current fees for the service at the time of the visit are £379.07 to £425.00. Information on the Home services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is allaboutcareltd@btconnect.com. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place over one day. All the key standards were looked at during the visit and special attention was paid to the requirement and recommendations identified in the previous report. The homes registered manager was on duty and was available to assist in the inspection process. The service users and the staff on duty were helpful and co-operative throughout the visit. The following methods of inspection and information gathering were used: one-to-one discussion with people who use the service, staff and management. Staff interactions with clients, care interventions and activities were looked at. Individual support plans risk assessments were discussed. Selected policies, medication charts and training programmes were seen. A tour of the building was undertaken. The views of visiting professionals were also sought. What the service does well: The registered manager of The Hailey has the competency, experience and skills to manage the home to a good standard. She is able to demonstrate a clear sense of direction and leadership, which the staff and clients understand and relate to. The home is well managed. Prospective clients and their families can visit the home and access the necessary information to help them decide whether or not The Hailey will be the right place for them to live. The home provides a relaxed, friendly and welcoming environment for clients to live in and for staff to work in. The people living at the home are encouraged and supported to do as much as possible for themselves. A resident said ‘they are here if you need them, we are looked after well’. Clients are able to make decisions and have choices on how they live their life’s. Privacy and dignity is maintained. Life at The Hailey is flexible and safe. The care staff on duty were seen to interact with the residents in a respectful and caring way. They said “that the staff are always very helpful and would do anything for them”. Staff are enthusiastic and take pride in the work they do. Clients reported that the food is always good, there is always enough and they always have a choice of menu. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 6 After speaking to staff, the manager, relatives and visiting professionals the feedback is that the home provides a good service and meets the of needs the people who live there. The registered manager and staff team maintain the vast majority of documentation in good order. All health and safety records were up to date and plans and records were generally well maintained. What has improved since the last inspection? What they could do better: . The registered manager needs to make sure that the staff are adhering to safe practises when administering certain medications. She also needs to make sure that they administer medication in a way that is individualised and respects the dignity of clients. The manager needs to make that all the necessary safety employment checks are done before staff work at the home. This is to ensure the safety and protection of the clients and minimise risks. Staff need to receive the required training The home needs to make sure all pre employment checks completed and in place before staff start to work at the home. All staff need to receive the necessary training to enable them to develop the skills and knowledge required to look after all the clients and keep them as safe as possible. Training needs to be up-dated and on going. All members of staff need training in safe guarding the residents from all forms of abuse. The cooks in the home need to achieve their intermediate food hygiene certificates Some bedrooms and landing areas need up grading and re-decoration. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 7 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. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients receive sufficient information to enable them to make an informed choice about living at the home. A competent person will undertake a full assessment of their needs prior to them coming to the home. EVIDENCE: The home has a statement of purpose and service users guide, which contains suitable information regarding The Hailey; it’s facilities and other aspects of the service. These documents have been reviewed and contain up to date information. The guide aims to provide all the information that prospective clients would need to know before coming to the home. The home has developed suitable pre-admission assessment processes, which are supported by CPA (Care Programme Approach) care plans, risk assessments and other background information. A sample of assessments was looked at. The home completes a baseline assessment covering a range of needs, all of which contributes to the development of the individual care plans. Assessments are undertaken by person with the necessary skills and knowledge to undertake the role. The manager needs to ensure that all assessments are done to the same good standard. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 10 Individuals are invited to the home for introductory visits and can stay over night if they wish. The first 4 weeks at the home is a trial period and following this time a review is held with the resident, care manager, registered manager and family to find out if the placement is suitable and if the person wants to continue living at the home. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of the clients are supported and met. They can be sure that risks will be identified and kept to a minimum. Clients are able to make decisions and choices about their daily lives. EVIDENCE: A number of individual plans were looked at during the course of the inspection, all of which have been fully updated and reviewed. Individual needs are identified and the action required by the staff to meet the needs is clearly documented. The plans are easy to understand and follow. They set out, in good detail, the needs aspirations and relapse indicators of each client. They provided clear guidance to enable staff to meet those needs. The care files only The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 12 contain the information needed to meet all the daily needs of the clients. Staff said that they use the plans on a daily basis. The care plans could be cross-reference with other documentation to ensure that they are being used effectively. Most clients receive a full review on a regular basis; the registered manager does need to ensure that full review is organised for everyone every 6 months. Following reviews there was evidence to show that plans are up-dated to reflect changing needs. There are also risk assessments in place, which run in conjunction with the care plans and relevant CPA documentation. The risk assessments are written in adequate detail and provide guidance to enable staff and clients to minimise risks whilst encouraging independence and responsible risk taking strategies. People living at the home are supported and encouraged to make decisions about their lives. The manager has information about advocacy services but to date no one has accessed the service. It was evident that there are issues affecting some clients that may be assisted by the provision of an independent advocate. The registered manager agreed to look into this. The people living at the home are encouraged to and able to participate in many of the aspects of daily life in the home. These include household tasks and responsibilities as well as input into menu choices, resident meetings and other aspects of daily living. All information in the home is retained in a confidential manner and staff are provided with training through the induction process relating to confidentiality. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 14, 15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have opportunities to take part in appropriate activities inside and out-side the home. Family relationships are well supported, and there are good relationships between the clients and staff. The home provides a healthy and balanced diet. EVIDENCE: Residents confirmed that the routines within the home are flexible and that they can choose, within appropriate boundaries, how to manage their time. The atmosphere in the home is relaxed and easy. Residents clearly stated that staff respect their personal space and that the routines in the house are flexible. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 14 One person said “its very easy going here, you can live your own life but there is help if you need it”. The home has a dedicated activities organiser and a day centre. There is an organised weekly programme of activities, which clients can participate in if they want to. It was reported that a programme of activities is developed in response to the current needs and goals of the client group. A number of residents also access resources outside the home including attendance at local colleges, sheltered and reintroduction to work schemes, voluntary work, mental health day centres and drop-in clubs. The home is located relatively close to the town centre and overlooks the sea. Therefore it is well placed to enable residents to independently access local facilities. There are reasonably good public transport links from the town including bus and train routes allowing access to larger places such as Canterbury. The home is flexibly staffed to enable clients who require support to access the local community as they wish. The people living at the home said that visitors are welcomed into the home and there is adequate space throughout the building for people to meet in private. The clients did report that they felt respected by the staff. They said their private space is respected and staff knock and await an answer before entering rooms. Residents have keys to their rooms and the building unless there is a specific issue of risk precluding this. Residents are encouraged to plan their time and are enabled to do so within reasonable boundaries. The home has a full-time cook and a weekend cook who develop menus in conjunction with client’s preferences and choices. Clear menu records are maintained demonstrating that a healthy, balanced diet is provided. Staff demonstrated an awareness of specific dietary needs. Mealtimes are unhurried and relaxed in a spacious dining room. Meals are presented in an attractive manner and residents are offered choices throughout. The cook has worked in the home for many years and is highly thought of by the residents. One resident said, “He knows what we like”. Another said, “you can ask for anything”. The cook was able to demonstrate a good understanding of residents needs. As identified at in the last report the cook does need to attain an intermediate food hygiene certificate, which is required for establishments in excess of 20 residents. This was once again discussed with the registered manager and the cook. Due to the size and complexity of the kitchen this area is only accessible by staff, but part of the extension to the rear of the home has a day centre which The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 15 includes a domestic kitchen where frequent meal preparation sessions are held including budgeting, shopping, food preparation and presentation. Many service users also have tea and coffee making facilities in their rooms. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides appropriate personal and healthcare support care for the service users. The homes for administering medication requires improvement to make sure clients are fully safeguarded. EVIDENCE: The Home operates a key worker system to provide sensitive and individual support to the clients. Most of the residents are generally self-caring requiring prompting and encouragement to attend to personal care needs at the most. Where staff are involved in supporting and assisting people with their personal care clear guidance is provided in care plans and residents are able to verbalise their needs and wishes clearly. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 17 The people living at the home can choose times for completing routine tasks such as having a bath, when they get up and go to bed. Routines are flexible. All the residents have access to a GP, mental health specialists and other healthcare professionals as required. It was reported that positive links have been established with the local community mental health teams and the registered manager stated that visiting CPNs and social workers are supportive. Visiting professionals who were contacted reported that they had a good relationship with the home. They said that the communication was good and any concerns or issues where reported promptly. They said that programmes of care were adhered to and the residents were receiving a service that meets their needs. Visiting professionals said, “ the home offers a good caring service”. “The staff report all necessary information promptly”. The healthcare needs, appointments and outcomes of any consultations are clearly documented and communicated through the staff team. Many of the residents are able to manage and take control of their own healthcare needs, but support is provided to attend appointments and reviews where required. The home has adequate policies and procedures in place with regard to medication issues and the policies and procedures relating to controlled drugs have been improved since the last inspection. Administration records were well kept and up to date, medication storage facilities were sufficient. The home uses the Boots MDS and staff have received adequate training in the administration of medications. Concerns were identified in two areas relating to medication. Medication was being delayed for a resident without discussion or guidance from any health care professional. There was no written evidence to demonstrate how and why this decision had been made and what the criteria was for the delay. The second issue was concerning the way in which medication was being given to residents. The practise was seen to be institutionalised and undignified. Both issues were discussed with the registered manager at the time. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s views are listened to and acted upon. Adequate processes are in place to protect residents from forms of abuse. EVIDENCE: The home has a clear complaints process in place; each client has a copy. There are also notices up in the home explaining what to do. Through discussion with a number of the clients it was evident that they felt comfortable about approaching staff, the registered manager and the responsible individual with any concerns or complaints that they might have. There have been no complaints regarding the home since the last inspection. The home has the appropriate Adult Abuse policies in place and also a Whistle Blowing Policy. The majority of the staff are aware of the policy, feel confident to use it if necessary and knew the appropriate action to take if they had to do so. The manager needs to make sure that all staff receive up to date training in safe guarding adults. There was evidence to show that some staff had not received this training. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are homely and comfortable providing a good range of private and communal space. There are suitable toilets and bathrooms throughout the home with facilities available for people with mobility problems. The home is clean and hygienic. EVIDENCE: The Hailey is on the Downs overlooking the sea on the outskirts of the centre of Herne Bay. The property has been extended to the rear providing purpose built bedrooms and a day centre. Despite the size of the building there is a homely and comfortable atmosphere with good quality décor, furnishing and fittings throughout most of the building. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 20 A number of bedrooms were viewed during the course of the inspection, which are all of adequate size. They are individualised and reflected the personalities of the residents. The new bedrooms in the extended area of the home all have doors leading to the garden/courtyard enabling freedom of movement, light and ventilation. All of the rooms viewed have adequate furniture and fittings. The clients said that they like their rooms and they had a choice in the way their rooms are decorated. There are a few bedrooms and landing areas that still need redecoration and up grading. The home is working towards this. There does need to be a planned renewal and maintenance programme in place with time scales for the fabric and redecoration of the premises. This was not available at the time of the visit. There is a good range of communal space throughout the service with a number of lounges and a smoking room amongst them. There are also adequate staff facilities. There is a courtyard area and a large garden, which is accessible to all. There is a good distribution of toilets and bathrooms conveniently located throughout the premises. The majority of the home was maintained to a good standard of cleanliness and appeared well cared for. Laundry facilities are adequate for the needs of the home and there is a part-time laundry assistant. The kitchen area also appears adequate for the needs of the home and, although access is restricted to staff. Clients can use other kitchen facilities in the home to make drinks and snacks outside routine times. It was reported that the home meets the requirements of the fire and environmental health departments. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the people living at the home. Positive relationships have been formed. On-going training needs to be in place to make sure the staff have the competencies and skills to meet all the needs of the residents. The residents are not fully protected by the home’s recruitment practices. EVIDENCE: The residents and care staff reported that they have developed good relationships with each other. It was observed that the staff are able to anticipate and meet the individual needs of the client group. The clients responded positively to staff. It was seen that the staff are accessible and approachable. They are able to exhibit good listening and communication skills. It was evidenced that the staff on duty put the needs of the people living at the home first. Staff are enthusiastic and positive about their roles in supporting and caring for this client group. They were able to give good The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 22 accounts of the needs of the people at the home and how those needs are met. It was evident that the staff took a pride in the work that they do. The staff did report that there have been recent changes made at the home, which had affected the moral of the staff group. They said they felt well supported by the homes manager but felt undervalued by the external management of the home. They said they were not listened to. This was reflected in the staff surveys that had recently been collated. The staff also said that this did not affect the their work and role with the people living in the home. Staff said ‘the residents come first always. They get everything that they need. We have a good team’. A resident said ‘ they are really good here; they will do anything for you. I feel safe’. There is a stable group of staff working at the home who have been there for a long time. A visiting professional said, “The senior staff are ‘spot on’ with the care they give”. Due to changes in shift pattern there are periods throughout the day and night when staff numbers have reduced. The manager stated that there are adequate numbers of staff on duty at all times to meet the present needs of the clients. If needs changed then staffing numbers would be reviewed. The staffing levels offer flexibility to support service users in and out of the house as required. The home also has a good team of ancillary staff including a full-time cook and a weekend cook, a number of domestic staff, a maintenance man and a laundry assistant. Over 50 of the staff team have achieved a National Vocational Qualification (NVQ) Level 2. Shortfalls were identified in other areas of staff training. From looking at the evidence it was seen that some staff have not received the required mandatory training even though they have been at the home for a considerable period of time. There was no up to date record of staff training and it was evidenced that training has not been up-dated or on going. There are also gaps in specialist training. Staff need to gain the knowledge and skills they require to undertake their role effectively, efficiently and safely. The home needs to ensure that this short fall is addressed and that training is planned and on –going. A sample of staff files were looked. Information about the staff is kept in 2 different places within the home. The registered manager does not have easy access to all the information she needs to ensure that files are up to date. At this visit shortfalls were identified in this area. Information on CRB checks was The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 23 not up to date. Not all files contained 2 references. The registered manager must ensure that a full employment history is obtained from all prospective staff and that any gaps are explored at interview. All files also need to contain an up to date picture of the staff member. All staff receive regular supervision. Those spoken to said that they found it beneficial. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at the home benefit from a well run service. The home has registered manager in post who has the necessary qualifications, experience and skills to offer leadership guidance and direction. The company encourages review and development of the service thus benefiting and improving the service users life style and safety. The health, safety and welfare of the residents is promoted and protected. EVIDENCE: The registered manager is competent, experienced and skilled to manage The Hailey. She has many years of experience working in care and has managed The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 25 other homes in the past. She is committed to improving the standard of care for the people at the home. There is a strong ethos of being open and transparent in all areas. She is able to communicate a clear sense of direction and leadership, which the staff and the clients responded to. It was evident that the registered manager possesses a good understanding of the needs of individual clients and of mental health issues in general. Staff spoken to commented on her positive management style and stated that she is approachable and valued within the team. The responsible individual takes an active role in the service and operates from an office on the top floor of the home. It is evident that on going improvements are taking place. The home now has effective quality assurance and monitoring systems in place and they have collated information from surveys. The home now needs to evidence that they are acting on the information they have received and gathered to improve the service. The home does need to undertake regular audits of their records and paperwork so any shortfalls can be identified and addressed. . A range of health and safety documentation was viewed all of which was well maintained and up to date. All service certificates and maintenance checks have been completed and safe systems for working instituted. Fire safety records were up to date and accident records maintained. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 1 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 3 X The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 27 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 YA20 Regulation Requirement Timescale for action 07/09/07 2 YA34 3 YA35 13(2) The manager needs to make Sch.3(3)(i) sure that specialist input is sought and robust guidelines are in place for staff when they delay the administration of insulin. All staff need to administer medication in a way that is person centred and dignified. 19 Sch.2 The registered manager needs 07/09/07 to make sure recruitment policies and procedures are adhered to and all checks are completed before a person starts to work at the home. 18(1)(c) The home needs to ensure that mandatory is up-to date for all 31/12/07 staff. The home also needs to ensure that all staff receive specialist training to ensure that they have an understanding and knowledge of residents conditions and how to best meet individual needs. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard YA17 YA23 YA24 Good Practice Recommendations To ensure both cooks achieve the intermediate food hygiene certificate. All staff need to receive training in safe guarding adults. There does need to be a planned renewal and maintenance programme in place with time scales for the fabric and redecoration of the premises. The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 The Hailey DS0000058573.V345760.R01.S.doc Version 5.2 Page 30 - 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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