Hailey House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At the last inspection, the provider was in breach of the regulations because they had failed to ensure staffing deployment and training was in place, the environment was clean, safe and well maintained, people were involved in risks to their wellbeing and medicines management was not safe. At this assessment, people’s care and support, staffing, medicines, the premises and management oversight had improved so people’s experience of care overall had improved significantly. Improvements had been made and the provider was no longer in breach of the regulations relating to the question of Safe. People received safe care from staff who understood their personal and health care needs and followed healthcare guidance from professionals. People received care from staff who were suitably skilled and competent. Staff knew how to safely support people around their individual risks. The provider ensured people were safe and received care which met their individual needs, protected their rights, and safeguarded them from abuse and neglect. Medicines administration was managed safely by competent and trained staff and infection prevention and control practices had been improved.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were more involved in helping to develop the service. This included choosing the colours of paint for redecoration, food and drinks served, social and leisure activities. People told us they could make complaints and would be listened to.

The manager showed us how they analysed incidents, accidents and complaints to identify any common themes, patterns and lessons learnt. Action was taken to learn from and address lessons learnt, this included reviewing people’s care needs and staff knowledge and training.

There were clear processes to record incidents, complaints, and compliments. Clear processes were in place to investigate, analyse and learn from incidents. The manager had created a learning culture where staff could raise and discuss issues and concerns during supervision and staff meetings, enabling staff to reflect and share ideas of how to improve things further.

People were supported to access different health and social care services when needed and their care was well coordinated. The service provided long term, short term and respite stays for people. These were coordinated so that there was continuity of care for people from hospital or their home.

The manager communicated with other services, assessed, and reviewed people’s needs and ensured smooth transitions between healthcare services.

The service worked well with other professionals. A professional told us they had no concerns about the service.

People’s changing needs and new admissions to the service were discussed within the staff team and care was well-organised and monitored daily. Referrals for professional support were made such as GP, district nurse teams, speech and language therapy or social services for additional help and advice when needed.

People and relatives told us they were safe at Hailey House. A person said, “Oh yes I feel safe here.” A family member said, [Person’s name] feels very secure as it is very homely, and their room is as they want it.” Another family member told us, “[Relative] is 100 % safe. We have no concerns leaving them when we go each time.”

Staff undertook training in safeguarding people from abuse. We saw that knowledge was shared and reflective learning sessions enabled staff to discuss safeguarding and preventing harm to people. Staff told us how they kept people safe. A staff member said, “I know about safeguarding, if I see something isn't right someone is being hurt, I have to whistle blow. I know that safeguarding also involves respecting people's privacy.”

We saw that people were safe from harm and being treated respectfully.

The system for managing and recording of safeguarding concerns had been improved and was now detailed and robust. The manager demonstrated how they learnt from incidents which affected people's safety. They shared concerns quickly and worked well with relevant local authorities to be open and transparent in any investigation. The manager had implemented a process of thorough investigation, actions and outcomes and lesson learnt to prevent them from happening again.

People and their relatives were involved in discussing risks to their health and safety. People’s care plans recorded discussions about risks, ways to mitigate them and making choices and decisions about their day to day lives. A person said, “I am able to say when I want to go out and make my plans.” A family member said, “I have been involved with my [relative] in a pre-assessment and building a care plan.

Staff supported people to remain safe and well and were aware of potential risks to their health and wellbeing. The manager told us, “We try to involve families and friends in capturing people's life stories, so we get to know who they are and can continue to live their lives as they choose.” A staff member told us, “Risk assessments are located in care plans, and we have enough time to read this, and all information is provided by the management which is essential for us.”

We observed staff involving people in conversation and listening to their views and body language. Care plans contained well written information to provide staff with the knowledge in how to support people to make decisions and choices.

Systems to involve, discuss and assess risks with people had improved significantly. Risks were appropriately assessed and documented. People’s capacity to make decisions was also considered and any barriers to involvement were removed through effective communication and engagement.

People and their family members were happy that the service was being improved. A person said, “I had my bedroom painted in the colour I wanted, it’s very nice.” A family member told us, “I am so glad they are doing the place up and its starting to look nice now. We can notice the changes being made and it’s good to see.”

At our last assessment, we found the premises to be poorly maintained. Significant improvements had been made and the provider was no longer in breach of the regulations. An improvement plan for the renovation of the service had been developed and was underway. The provider told us, “We are pleased with the work on the premises we have done to date and all work planned is on target. We have employed a maintenance person with the right skills to do some of this work and people can see the action we have taken to make the service a place where people can call home.” Staff told us the service was homely, and they felt proud to work at Hailey House. A staff member said, “It is good to see all the work being undertaken to make the home better for people.” Another said, “Improvements are being made all the time, it can only get better. If I could change something about the service, it would be to have a nice garden for people to use.”

Safety measures had been put in place for people and staff. For example, a gate had been installed in the corridor leading to the kitchen and on the upper landing near the back staircase. These measures were implemented to enhance people’s safety by restricting access to areas where there is a risk of falling or entering unsafe parts of the service. The creation of an additional walk-in shower room upstairs was nearing completion. The kitchen area was well maintained and all repairs completed, for example tiles had been replaced around the sink and the kitchen hatch had been boarded up at the advice of the fire service. Fridges were in working order and food was stored at the required temperatures. The lounge, dining room and bedrooms had been repainted with colours of people’s choice. Improvements to paintwork, skirting boards, some of the stairways and doors around the building were still in need of refurbishment. The gardens around the service had been cleared of old sheds and debris. Plans were underway to create a garden people could enjoy. A family member told us, “I can’t wait for this to be completed so that [relative] can use the garden and start to grow some vegetables.” The work and maintenance of the laundry room had been completed. New washing and drying machines had been purchased making it easier for staff to manage the day-to-day laundry. The external environment at the front of the house had been painted. Some repair was still needed to windowsills and guttering but this was part of the maintenance plan.

There was a system to monitor health and safety. These included fire safety measures and people’s up to date personal emergency evacuation plans. Daily, weekly, monthly and quarterly checks were undertaken to ensure all aspects of the service were safe. This included equipment, maintenance, medicines administration, cleaning, finance and care plans. The provider had a business continuity plan which provided guidance on contingency plans in case of various emergencies and untoward events that could affect the service. Accidents and incidents reports were completed and detailed about what had happened and how risks were being mitigated to keep people safe. Lessons were learnt as a result.

People told us there was enough staff to care for them. A person told us, “[Name of staff member] comes and sits with me, we talk about anything and everything.” A family member said, “Always seems to be plenty of staff around when we visit and we are always welcomed.” We observed staff talking to people calmly and in an unhurried way. They checked and monitored people in their rooms regularly. One person used their buzzer to alert staff as they wanted to go into the garden. Staff were quick to attend.

The rota arrangements had the required number of staff on duty and all shifts were covered on the rotas we saw. This included night staff with experience of administering medicines. If any staff called in sick or were on annual leave, existing staff provided extra cover. Staff were deployed around the service to ensure everyone received care that was person centred and met their needs. Improvements to the kitchen staff had been made. Two cooks worked alternative shifts to ensure there as always cover in the kitchen seven days a week. Staff told us the new staff team created over the past year was working really well. Staff said they had the time and the skills to meet people’s needs and promote their independence and confirmed agency staff were no longer used. One staff member said, “It is good working here, there is no pressure on us. There is no stress when I go home. It is like caring for family. If we want to sit and talk to people, we can. All the staff get on well, we are a small team.”

We saw staff had the skills and experience to provide good care for people. There were enough staff to support people safely.

People's dependency needs were assessed to calculate the number of staff needed to provide people with appropriate care and support. For example, the needs of people who used a hoist, at risk of falls and those who needed 2 staff to support them. Staff induction was thorough, and staff felt welcomed to the service. Staff completed the mandatory training needed for their role and this was up to date. Their training needs were reviewed to ensure they had the knowledge and skills to meet people's needs. Knowledge checks and information sharing sessions had been introduced to discuss new ways of working and new processes, so everyone understood their role and responsibilities. Staff received regular supervision which recorded discussions and performance. Team meetings were inclusive and there was a clear action plan and follow up from the meetings to ensure continued improvement. New staff were recruited following a robust recruitment process. Disclosure and Barring Service (DBS) checks were undertaken to ensure staff were safe to work with people. DBS provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

People were protected from the risk of infection because the premises and equipment were kept clean and hygienic. People’s assessments were updated for anyone prone to or at risk of infection such as a urinary tract or chest infections to ensure staff knew the signs to look for and action taken quickly.

Staff were aware of their responsibilities to keep the service clean and infection free in order to keep people safe. There was enough personal protective equipment [PPE] for staff to use. Staff had received updated training in using handwashing and PPE to reduce the risk of infection. Equipment including hoists and wheelchairs were clean and well-maintained by the staff and serviced when necessary. People's hoist slings were washed weekly and kept in their rooms.

We observed the service to be clean, free of odours and hygienic.

Infection prevention and control systems had been improved. Cleaning rotas, daily, weekly and monthly comprehensive audits and records were in place. Legionella and other environmental tests were completed. and the laundry arrangements had changed to segregate washing items. Pest control was being managed and a contract with a specialist company was in place should the service need it. The provider's infection prevention and control policy had been reviewed and was up to date containing relevance guidance and arrangements to prevent and control the risk of infection.

People were given their medicines as prescribed. Their choices about how they liked to be given their medicines were recorded. We observed people being given their medicines. A person was offered a drink with their medicines in the way the person preferred. The staff member waited with them to ensure they had taken their medicines in a safe way. A family members told us, “I went through [relative’s] medicines with staff and was involved in their care plan as well.”

Staff were able to explain practises to manage peoples’ medicines and reduce the risk of errors. Staff followed recommended best practice when dispensing and administering medicines. For example, administering 'as and when required' (PRN). Information and records to support staff with administering medicines were in place. Staff were aware of people’s rights to decline medicine and the process to follow should this occur. A staff member told us, “There are protocols in the place. We are trained to look at gestures, facial expressions, body languages, eye movement. If person is not in a good mood, is unsettled, has an unusual reaction or is confused, we report this and record it, so that we do the right thing for that person.” Staff were trained and available when people needed prescribed or PRN medicines. A staff member told us, “Giving people their medicines is the best part of my job. I take particular pride in organising the medicines trolley and keeping the medicine room tidy.”

The systems and processes in place to safely administer and record medicines use had been improved. Medicines were stored safely in line with manufacturers recommendations. Medicine audits were completed to monitor the medicines management system. Checks undertaken were robust and any concerns or lessons learnt addressed and additional training put in place where needed. The provider had a medicines management policy and staff members’ competency was regularly assessed.