Inspection on 06/07/06 for The Hailey

This inspection was carried out on 6th July 2006.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Hailey 30/08/07

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 Joseph Harris Unannounced Inspection 6th July 2006 10:00 The Hailey DS0000058573.V301621.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.V301621.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.V301621.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 742969 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) All About Care Ltd 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.V301621.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The condition that continued registration is conditional upon the application process being Satisfactorily completed by 31st December 2003 20th February 2006 Date of last inspection Brief Description of the Service: The main part of the premises are two older two-storey properties which have been joined together and adapted for their present use. The accommodation for service users 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 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 current fees for the service at the time of the visit are £369.51. 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.V301621.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 6th July 2006 and started at 10am lasting for around 7 hours. During the course of the inspection discussions were held with a number of service users, staff, the registered manager and deputy manager and the responsible individual. A tour of the premises was conducted viewing communal areas, bedrooms, the day centre, kitchens and laundry area. A range of records were viewed including those relating to service users, staff and the day-to-day running of the home. What the service does well: What has improved since the last inspection? It was reported that the home has advanced and progressed consistently over the past few years. There were no requirements or recommendations at the previous inspection. The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 6 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 Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 7 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.V301621.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Prospective service users are provided with adequate information regarding the home. Individual needs and aspirations are assessed prior to admission and service users know that the home will be able to meet those needs. There are sufficient opportunities to spend time in the home before an individual chooses whether to move in. Each service user is provided with a written contract. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has developed a statement of purpose and service users guide containing all relevant information and that is subject to periodic review. These documents are available within the home and a service user guide provided to all prospective service users at the point of referral. The registered manager has developed a good assessment process including a detailed assessment tool that is required to be completed by the referrer. This tool addresses the holistic needs of the prospective service user including any potential risks and restrictions. In addition to this copies of Care Programme Approach (CPA) documentation are also requested. On review of these documents the individual is invited to the home for a short introductory visit and additional visits thereafter increasing to overnight stays if desired. Once a service user decides to move in to the home and needs have been fully assessed the first 4 weeks of the placement are considered a trial period following which a formal review is held with the resident, care manager, the The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 9 registered manager and any significant others to determine whether the placement should continue. The home ensures that it can continue to meet service users needs and variations to registration have been gained for some people who are now over the age of 65. There is a committed and knowledgeable staff team supported by an experienced registered manager. Each service user is provided with a written contract covering fees and other key aspects of the terms and conditions of residency. A copy of this is retained by the service user and a copy kept on file. The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. A service user plan is developed addressing the needs and goals of each individual. Service users are enabled to make decisions about their lives and are consulted and able to participate in the running of the home. A positive risk management structure is in place. Information is retained in a confidential manner. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has an individual plan of care developed addressing needs, goals and perceived risks. Three service user plans were randomly selected and examined in detail. All of which addressed needs in sufficient detail and provided clear guidance for staff. One plan in particular provided good guidance with regard to potential episodes of self-harm and another plan would benefit from a similar form of action plan to address a complex issue. This was discussed and explained to the registered manager who agreed that the plan in question could be further strengthened. All service user plans showed clear evidence of review and were updated to reflect changing needs The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 11 outside of the regular review times. The plans are set out in a ‘user-friendly’ format with ‘live’ information at the forefront of the file and archived information to the rear. The home also develops risk assessments in conjunction with the service user plans and relevant CPA documentation. The risk assessments are written in adequate detail and provide guidance to enable staff and service users to minimise risks whilst encouraging independence and responsible risk taking strategies. Service users are enabled to take decisions regarding their day-to-day lives and, where appropriate, are able to retain control over their finances and other aspects of daily living. However, a number of the service users do have reduced levels of capacity due to their health issues and, in some circumstances, age. A discussion was held regarding advocacy services and the potential benefits of independent advocacy. The registered manager stated that information was available regarding such services, but had not been considered at any length. Through discussion it was evident that there are issues affecting some of the service users that may be assisted by the provision of an independent advocate and the registered manager agreed to investigate this further. Service users 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. 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 with a domestic style kitchen for service users to develop essential life skills. Many service users also have tea and coffee making facilities in their rooms. 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.V301621.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Service users have opportunities for personal development and are able to take part in meaningful activities. Residents are enabled to remain part of the local community and have access to adequate leisure and recreational facilities. Visitors are welcomed into the home. Service user’s rights and responsibilities are respected. The home provides a healthy and balanced diet. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a dedicated day centre facility and an activities organiser who is able to develop activities and daily living programmes to meet the needs and aspirations of individual service users. The day centre includes a domestic kitchen where frequent meal preparation sessions are held including budgeting, shopping, food preparation and presentation. It was reported that a programme of activities is developed in response to the current needs and goals of service users. 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 Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 13 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 conurbations such as Canterbury. The home is flexibly staffed to enable service users who require support to access the local community as they wish. Service users reported that visitors are welcomed into the home and there is adequate space throughout the building for people to meet in private. The staff respect individual rights and responsibilities aspects of which were confirmed by residents. Service user’s 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 therapeutic boundaries. The home has a full-time cook and a weekend cook who develop menus in conjunction with service users likes and choices. Clear menu records are maintained demonstrating that a healthy, balanced diet is provided. Staff demonstrated an awareness of specific dietary needs of service users. 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 14 years as both a care worker and cook and demonstrated a good understanding of service user needs. It was noted that neither cook has attained an intermediate food hygiene certificate, which is required for establishments in excess of 20 residents. This was discussed with the registered manager and cook who agreed to make arrangements for enrolment on this course. Refer to recommendation 1. The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Service users receive personal support in a manner that suits their needs. Healthcare needs are met. Medication systems are in place to promote safe administration. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff in the home provide personal care to a number of the older residents. However the majority of service users are generally self-caring requiring prompting and encouragement to attend to personal care needs at the most. Where staff are involved in supporting people directly clear guidance is provided in the form of care plans and service users are able to verbalise their needs and wishes clearly. Service users can choose times for completing routine tasks such as having a bath, when they get up and go to bed, etc. The home operates a key worker system. The home ensures that all service users 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 on the whole. The home has raised concerns regarding the input of one social services team focussing independent living; these issues are beginning to be addressed however. The healthcare needs, appointments and The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 15 outcomes of any consultations are clearly documented and communicated through the staff team. Many of the service users 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. However procedures and facilities relating to controlled drugs need to be improved. These issues were discussed at the time of inspection. Refer recommendation 1. Administration records were well kept and up to date, medication storage facilities were sufficient in all other respects and the cupboard well maintained. The home uses the Boots MDS and staff have received adequate training in the administration of medications. The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Service user’s views are listened to and acted upon. Adequate processes are in place to protect residents from forms of abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints procedure in place that is provided to service users and is on display covering all relevant details. Through discussion with a number of service users 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. Adequate policies and procedures are in place relating to adult protection and abuse awareness. Staff also address such issues through the induction programme and by participating in additional training. Discussions with staff revealed that there is a good awareness of issues of abuse and how to report any concerns should they arise. The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. 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 was clean and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is situated 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. A number of bedrooms were viewed during the course of the inspection, which were all of adequate size. One of the features of the newer bedrooms in the extended area of the home is the fact that they all have doors leading to the garden/courtyard enabling freedom of movement, light and ventilation. All of the rooms viewed had adequate furniture and fittings and service users stated that they like their rooms and that they meet their individual needs. 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 The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 18 adequate staff facilities. There is a courtyard area and a large and attractive garden, which is accessible to all. There is a good distribution of toilets and bathrooms conveniently located throughout the premises. Some of these facilities have adaptations suitable for people with limited mobility and disabilities. The home was maintained to a very 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, service users 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.V301621.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. There are clear staff roles and responsibilities and a competent and stable staff team. There are adequate numbers of staff on duty at all times. The home’s recruitment procedures are adequate. There are some areas of the training programme that need updating, but the home is taking positive action to address these shortfalls. An adequate system of supervision is in place. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All staff members are provided with a job description on commencing employment and are required to review key policies and procedures as part of the induction process. Discussions were held with staff members on a group and individual basis. Staff spoken to showed a good awareness of the needs of service users, the aims of the service and mental health needs in general. Service users commented that the staff are very good, approachable and supportive. The staff demonstrated good levels of competency and awareness, with over 50 of the staff team having achieved a National Vocational Qualification (NVQ) and other staff working towards these awards. The home operates with 5 staff on duty throughout most of the day, reducing to 3 staff in the late evening. There are 3 waking night staff on duty throughout the night. 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 The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 20 maintenance man and a laundry assistant. The staffing levels offer flexibility to support service users in and out of the house as required. A number of staff files were viewed which demonstrated that the home operates a robust recruitment process ensuring all necessary checks are completed. The home does complete CRB and POVA checks, which are not kept on file, but are retained in the central office within the building. The home is working to ensure that all staff are provided with all mandatory training and additional training needs, although it was noted that there are some shortfalls within the mandatory training courses for some staff. The registered manager stressed the commitment of the service to ensure that all training is up to date and to provide staff with supplementary training to further develop skills. A mental health awareness course has been arranged for all staff including ancillary staff. Neither cook has achieved an Intermediate Food Hygiene Certificate, which is recommended for homes catering for 20 service users and above. Refer to recommendation 2. There is an adequate supervision system in place, with staff being given regular formal 1:1 supervision with a senior member of staff. Staff also commented that there is a supportive team including the manager and deputy manager and that if anyone has a problem or concern these are dealt with proportionately. There are regular staff meetings arranged. The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The registered manager is experienced and well qualified ensuring a well run home. There are quality assurance processes in place, but these need to be strengthened. The health, safety and welfare of service users is promoted and protected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for a number of years and has contributed positively to the on going development of the service. She has obtained all necessary qualifications and continues to strive for opportunities to develop her skills further. She has extensive experience in the field of mental health within a number of settings over many years in the health and social care profession. In discussion it was evident that the registered manager possesses a good understanding of the needs of individual service users and of mental health issues in general. Staff spoken to commented on her positive The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 22 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 considered and actioned. The responsible individual has a clear vision for the future direction of the service and has made significant improvements since taking over this role. A number of measures should be introduced, however, to ensure on going and measurable quality assurance outcomes. A system of monthly monitoring needs to be introduced including the random auditing of records and documents and discussions with staff and service users to identify areas of improvement and consolidation. A method of surveying service users and other stakeholders satisfaction should also be introduced culminating in the publication of an annual quality report identifying perceived strengths and weaknesses of the service. Actions arising from this should also be identified. Refer to requirement 1. 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.V301621.R01.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 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 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 X 2 X X 3 X The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA39 Regulation 24, 26 Requirement To introduce measurable quality assurance system including a monthly monitoring report and stakeholder/service user satisfaction questionnaires within the context of an annual quality report. Timescale for action 01/09/06 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 3 Refer to Standard YA17 YA20 YA35 Good Practice Recommendations To ensure both cooks achieve the intermediate food hygiene certificate. To review procedures and facilities to ensure safe systems for controlled drug storage and administration. To continue to work towards achieving up to date mandatory training for all staff. The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 The Hailey DS0000058573.V301621.R01.S.doc Version 5.2 Page 26 - 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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