Background to this inspection
Updated
7 July 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by 2 inspectors.
Service and service type
The Hailey Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. The Hailey Residential Care Home is a care home without nursing care. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received from the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 7 people about their experience of the care provided. We spoke with 7 staff, including care staff, the deputy manager and the registered manager. We reviewed a range of records. This included 5 people’s care records and associated risk assessments and multiple medicines records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies, audits and training records were also reviewed.
Updated
7 July 2023
About the service
The Hailey Residential Care Home is a care home providing accommodation and personal care to up to 40 people who require support with their mental health. At the time of our inspection there were 36 people using the service, 17 of whom received the regulated activity of personal care.
People’s experience of using this service and what we found
Risks to people’s health, safety and welfare were not consistently managed. Risk assessments, to provide staff with guidance on how to minimise risks, were not completed in some cases.
People received their medicines as prescribed. However, we identified an area for improvement around the recording of application of prescribed creams.
Recruitment processes had not been consistently followed and we identified this as an area for improvement.
Checks on the safety and quality of the service were not consistently effective or robust. When feedback had been received from people or staff, this had not been analysed. There was not an effective system to ensure feedback was followed up to ensure improvements were made.
People were supported by enough regular staff who knew them well. People were supported to go out for activities and appointments. Staff understood how to protect people from the risks of abuse and knew how to report any concerns.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People spoke positively about the service, and it was clear staff knew people well. Staff felt valued and supported by the registered manager.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 4 December 2018).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Hailey Residential Care Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to risk management and governance.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.