Hailsham House

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Staff understand their role and responsibilities. Staff felt supported in their roles. The provider worked collaboratively with healthcare professionals. Where accident and incident reports had been completed, they had not been consistently reviewed to mitigate the chance of reoccurrence or analysed to identify any patterns or trends. Audits had not identified some of the concerns found during the assessment process. This was fed back to the provider who immediately addressed these with robust actions. However, time is needed to embed these into everyday practice.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The manager demonstrated a good understanding of the regulatory requirements. They told us they analysed and reviewed audits each month and actions were taken to address shortfalls. However, there was no evidence of what actions were taken to prevent a reoccurrence. Staff understand their role and responsibilities. Staff had job descriptions and received support from the management team to ensure they had the necessary training to do their role well. The manager was proud of the staff and the improvements in staff morale. The manager monitored staff performance by three monthly supervisions and yearly appraisals. This was confirmed by the staff we spoke with.

At the last inspection there was a breach relating to governance. The provider had not ensured that there were effective systems to assess, and quality assure the service and had failed to maintain accurate, complete, and contemporaneous records in respect of each service user. At this inspection we found that whilst improvements had been made, there were still areas to improve. The management team immediately put in actions to mitigate risk and resolve the concerns highlighted. The management team completed monthly audits to monitor the service and people’s experiences. However, we found that their audit processes, whilst in place, had not identified improvements that were needed in respect of prevention of accidents, incidents, and complaints. The safeguarding log gave a brief description of the safeguarding concern, but no record of what investigation was completed, and outcomes or lessons learnt. This meant that lessons were not being learnt and reflected on. It was identified that not all notifications were completed and some were not completed in a timely way. For example, a safeguarding referral and notification were not completed until 21/5/2024 although the incident occurred on 24/4/2024. Improvements were needed in respect of the recording and management of wounds. This was acknowledged and new documents have been introduced that will record the status of wound in line with best practice guidance. Infections such as sepsis were not being reviewed, as to probable cause and no root cause analysis completed. Some staff told us that they had not received any training in sepsis awareness. The manager has arranged training and introduced a folder for staff to refer to. Documents relating to the management of behaviours were not inline with best practice as they did not contain sufficient information. This was fed back to the provider to address.

People and their relatives told us appropriate health and social care professionals were contacted appropriately when required. A person told us, “I can see a GP, Chiropodist and Hairdresser.” A relative told us,” Very good here they tell us when the GP is seeing[person] or keep us updated regarding medicines.”

Staff told us they worked closely with external professionals and were confident to contact someone directly without hesitation. The management team were proactive in building relationships with other organisations and into the local community to improve outcomes for people. The manager said that they were reaching out to the local community to be involved with Hailsham House and making people part of their local community. They had close links with the local authority and utilised any additional training opportunities when they were offered.

Healthcare professionals contacted during this process were positive about the staff at Hailsham House. They told us people were referred to them appropriately. A healthcare professional told us, “When we come across any issues such as wounds or dermatological issues, we provide feedback to the home, and they act on this accordingly. We provide accurate note keeping for all residents. We have found the staff very helpful and the continuity with staff and knowing the residents is really noticeable. Hailsham House is a lovely caring residential home that we are proud to work with on a regular basis” and “The staff are happy and smiling and are approachable.”

Staff worked with various external agencies including, GPs, community nursing teams, social workers, and Local Authorities. Relevant information was shared appropriately.