Please wait

Inspection on 28/11/07 for Haxby Hall - City of York Council

Also see our care home review for Haxby Hall - City of York Council for more information

This is the latest available inspection report for this service, carried out on 28th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People are cared for by staff who are competent and well trained. One comment made was "the staff are so kind and caring". The home is clearly run in the best interest of people using the service and their visitors.People are able to raise their concerns in an open and transparent manner and are confident that they will be effectively addressed.

What has improved since the last inspection?

The cleanliness of the home has improved. People live in a fresh smelling and pleasant environment. One person said "my room is really clean and it always smells nice". People have their nutritional needs assessed which ensures that people who are underweight or overweight are identified and appropriate action is taken. The risks of burns and scalds from excessively high water temperatures has been reduced, regular temperatures are taken and adjustments are made where necessary, this protects people from harm. Medication is stored more effectively which reduces the risk of any adverse incidents occurring. Staffing levels have been reviewed, though this needs to continue because of the fifteen high dependency beds.

What the care home could do better:

Aspects of the medication system need improving, this includes regular audits which will identify any errors that have occurred. The system for recording people`s finances needs to be more robust, this will ensure the amount of money kept in the home tallies with the amount recorded. Some people would benefit from having more activities to participate in. The type of food served needs to be reviewed to ensure the food offered is the food people want.

CARE HOMES FOR OLDER PEOPLE Haxby Hall - City of York Council Haxby Hall York Road Haxby York North Yorkshire YO32 3DX Lead Inspector Jo Bell Key Unannounced Inspection 28 November 2007 09:30 X10015.doc Version 1.40 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 Haxby Hall - City of York Council DS0000034916.V333772.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 Older People. 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. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haxby Hall - City of York Council Address Haxby Hall York Road Haxby York North Yorkshire YO32 3DX 01904 768944 01904 766289 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) www.york.gov.uk City of York Council Mr Andrew Lee Hart Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49) of places Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th December 2006 Brief Description of the Service: Haxby Hall is a care home run by City of York Council and is registered to provide a service for 49 older people of either gender aged 65 years . Within this service there are fifteen high dependency beds which are located on the ground floor. The home was purpose-built approximately 35 years ago and is located just off the main street in Haxby. The home is only a short distance away from the village amenities. There is a car park to the front of the home and gardens to both the rear and side of the home. The accommodation is provided on two floors in single rooms. The upper floor is accessible via passenger lift. The fees per week are £432. Additional charges are made for hairdressing, chiropody services and individual items like toiletries. The service provides an information booklet about the home to prospective residents. The Statement of Purpose and service user guide, which gives information about the home is available, with a copy of the latest inspection report, for people to read. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is what was used to write this report. • • • Information about the home kept by the Commission for Social Care Inspection. Information asked for, before the inspection. This is called an Annual Quality Assurance Assessment (AQAA) Information from surveys, which were sent to people who live at Haxby Hall, their relatives, and other professional people who visit the home. 10 were sent to people at the home and 4 were returned. 3 were sent to peoples’ relatives, though none were returned. 3 were sent to GP’s, 3 to Care Managers, though none were returned. A visit to the home by one inspector, which lasted six hours. This visit included talking to people who live there and their visitors. The manager, the deputy, cook, two care leaders, three care staff and a community nurse were all spoken with during the day who discussed the home and the care provided. The visit also included checking some of the records, policies and procedures that the home has to keep. • Information about what was found during the inspection was given to the home manager at the end of the visit. Haxby Hall have made significant progress during the past twelve months, the home is well managed with people receiving a good standard of care in a pleasant environment. What the service does well: People are cared for by staff who are competent and well trained. One comment made was “the staff are so kind and caring”. The home is clearly run in the best interest of people using the service and their visitors. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 6 People are able to raise their concerns in an open and transparent manner and are confident that they will be effectively addressed. What has improved since the last inspection? What they could do better: Aspects of the medication system need improving, this includes regular audits which will identify any errors that have occurred. The system for recording people’s finances needs to be more robust, this will ensure the amount of money kept in the home tallies with the amount recorded. Some people would benefit from having more activities to participate in. The type of food served needs to be reviewed to ensure the food offered is the food people want. Haxby Hall - City of York Council DS0000034916.V333772.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. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable) People who use this service experience good quality outcomes in this area. Needs are effectively assessed before people move into the home to make sure the appropriate care and support is offered. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People have their needs assessed initially by the care manager, and then the home manager carries out a further assessment to ensure the home can meet individual needs. Details include health and personal care needs, social life and previous medical information. People making enquiries about moving to the home are given information about the service, including the latest inspection report from the Commission for Social Care Inspection. This helps them in making a decision as to whether the home is right for them. They can also look around the home and talk with some of the people living there. All people who move to the home are offered a trial period. A meeting is then held to Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 10 determine whether the person is going to stay there. Three assessments were inspected and these all contained detailed information. The manager is aware of the criteria for accepting a person to one of the fifteen high dependency beds or to the low or medium dependency beds, where needs will differ. People spoken with confirmed that an assessment had taken place and that the manager had asked them questions regarding their needs. Intermediate care is not provided at Haxby Hall, though respite care both planned and emergency is offered for up to two people at any one time. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 People who use this service experience good quality outcomes in this area. Health and personal care needs are met in a dignified manner. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People are well cared for, staff know the people living in the home well and have a good rapport and interact well with people using the service and their visitors. People spoken with all confirmed that their personal care needs were always met. Three care plans were inspected and two were detailed with a range of information relating to health and personal care. Risk assessments are undertaken relating to self medication, moving and handling and the prevention of falls. The home have implemented nutritional assessments in the past few months which help to identify if people are at risk from being either under or over weight. Care plans are reviewed and evaluated by the care leaders on a regular basis and key workers complete a daily contact sheet with up to date information regarding any changes in care. One person had been Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 12 admitted two days ago, and whilst no paper work had been completed other than the initial assessment staff confirmed that the information will be in place in the next few days when the person has settled into the home a bit more. Information regarding life history needs to be more detailed which will help when activities are organised. The manager is aware of how to report incidents including accidents with a Regulation 37 notification to the CSCI. Accidents are audited and any patterns are identified and appropriate action is then taken to minimise the risk of harm. Staff are very aware of how to seek further advice from doctors, district nurses, the infection control nurse or the continence advisor. Records of visits from healthcare professionals were evident in the care plans. One healthcare professional spoken with confirmed that advice is always sought and that the home have a good working relationship with the community nursing team. Privacy and dignity is maintained in the home, staff are observed knocking on people’s doors prior to entering, and the attitude and manner of staff throughout the visit was extremely positive. The medication system was inspected. Improvements have been made in the storage of the medication trolley and the blister packs containing the medication. The home administers controlled drugs and a register was available which confirmed that stock balances are taken. Two people sign when a controlled drug is administered. Two different types of controlled drugs were checked and these were stored, administered and recorded correctly. Three medication charts were inspected and it was evident that improvements need to be made in order to protect people from harm. Monthly stock balances are taken, one chart was checked where the medication was stored in the original box and not in the blister pack. Four different medications on this chart showed that the amount of tablets in the box did not tally with the amount recorded. It was unclear if the medication had been given or if it had been signed for and not given. Medication on two other charts also confirmed that the stock balances were incorrect. One of these was in the blister pack where there should have been twenty one omeprazole tablets left and there were twenty two. No formal audits of this system take place, this would help identify the errors which are occurring. Medication in the fridge was examined, three bottles of eye drops did not have a date of opening on them, and the date on the pharmacy label confirmed that if the medication was open on this date the eye drops would be out of date. i.e 28th August, and two bottles with 11th October on. Staff should be recording daily fridge temperatures to ensure medicines are stored at the correct temperature. The thermometer showed ten degrees centigrade, and most medication needed to be stored two-eight degrees centigrade. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 13 The manager was made aware of these issues along with the care leader at the time. Whilst these issues could be potentially detrimental to the people concerned it was very evident that the manager would be addressing the above issues straightaway. The manager confirmed that an audit would be undertaken, weekly stock balances would be introduced and the fridge temperature and issues with the eye drops would all be actioned following the inspection. This information would be forwarded to the CSCI as soon as possible. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 People who use this service experience adequate quality outcomes in this area. Some activities are available and autonomy and choice is encouraged. The standard of food and drink needs improving. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People have access to some activities and the home is having a Christmas fayre and tombola in the next few days. Visitors were observed buying raffle tickets for this event. Currently there is no designated person to organise activities, care staff are very busy caring for people with low, medium and high dependency needs and therefore do not have the time to spend planning and facilitating activities. This would enhance people’s quality of life. There have been trips out in the past twelve months (twenty six in total) though some staff have to help in their own time. People spoken to said they would like more one to one sessions, more arts and crafts, quizzes and entertainment. However, there is the television, music, newspapers and magazines available and visitors are encouraged to participate in activities where possible. One lady spoken to had been out for the morning with her relative, and people are encouraged to spend time in the garden. Some people are very mobile but do Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 15 not always get the opportunity to partake in activities due to the staffing levels. One person said “I do get a bit bored”, another person said “there use to be a lot more activities”. The manager is aware of this issue and understands the benefit it would bring to people if more activities were offered. Religious needs are catered for and this is discussed in individual care plans. Four visitors were spoken to all confirmed they are welcomed into the home at different times during the day, this was evident when inspecting the visitors book. The home encourage autonomy and choice and people discussed the times they can get up and go to bed, and their daily routines. The lunchtime meal was observed. Haxby Hall has a range of dining areas all of which are pleasant, light and suitable for people to dine in. Currently the home offers homemade food on an evening and morning and hospital food at lunchtime. In total ten people were spoken to who discussed their likes and dislikes regarding the food. Everyone without exception stated how they much prefer the home cooked food, the smell of cooking the home is appealing and gives people an appetite. A choice is offered at lunchtime and whilst the portion sizes were adequate many people left the hospital food, comments included “it has no taste” “I don’t know what I am eating” this referred to a herb dumpling and “the vegetables aren’t fresh”. The food from the hospital is microwaved and staff in the kitchen felt there was a plastic smell which was quite unpleasant. The cook was spoken to who was in the process of making homemade food for tea-time. Staff discuss if anyone is underweight or overweight and food is pureed and put on the plate separately. The kitchen was clean and a visit from the environmental health officer took place in July and no issues remained outstanding. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good quality outcomes in this area. People can be confident that their complaints will be addressed properly and staff are alert to signs of abuse which contributes to keeping people safe. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People spoken with felt very safe living at Haxby Hall and said that they would speak with the manager if they had any concerns. They were confident that any complaints would be addressed. One formal complaint has been made in the last twelve months which has now been concluded, this was partially substantiated. The manager is aware of his responsibilities regarding investigating any complaints made. One concern was raised at the visit regarding the temperature of the food served, and this was addressed straightaway. Staff attend abuse awareness training when they first start working. Staff were spoken with at the site visit and they all understood their responsibilities should they see or hear something, which may constitute ‘abuse’. The manager is aware of how to deal with allegations of abuse, a vulnerable adults procedure is in place which includes whistle blowing and the no-secrets document. This helps to protect people from harm. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 17 City of York Council carries out recruitment checks centrally. All staff have a police check before starting working for the organisation to make sure they have not been previously barred from working with vulnerable people. This good practice contributes towards keeping people safe. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use this service experience good quality outcomes in this area. The home is clean, warm and homely, which enhances the experience of living there. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home is located in Haxby with local amenities not far away. During the past twelve months some refurbishments have taken place. New carpets were evident and rooms have been redecorated. This has improved the environment. A new cleaning rota has been implemented and all areas of the home inspected were clean and well maintained. One person said “my room is always kept clean”, one visitor said “the room always smells lovely”. The atmosphere is pleasant and people enjoy living in the environment. There are a range of communal area where people can socialise in large or small groups or in private. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 19 Staff have previously undertaken infection control training and staff were observed wearing protective clothing and washing their hands effectively. The manager and deputy confirmed that staff know what action to take regarding infection control though they do not have to attend regular updates in this area. People were observed wearing clean, well ironed clothes and the home have sufficient washing machines and driers to meet people’s needs. The laundry room has a secure lock to ensure people using the service are not put at risk by going into this area and having to access to cleaning materials. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 People who use this service experience adequate quality outcomes in this area. Staff have the skills and knowledge to care and support people properly, though more staff would enhance the quality of life for some people. The recruitment process is robust so that people are being protected from harm. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People in the home receive care from competent and well trained staff. The manager is supernumerary and the deputy works with the staff as needed. Normally there are two or three care leaders on duty and four of five care staff. On a morning and evening when the care leaders are busy with medication, paperwork, dealing with healthcare professionals the care staff are very busy and it would be beneficial having up to two extra carers. As there are fifteen people who are high dependency this can be very time consuming for staff and some people require two carers. Invariably this may mean that people have to wait on an evening if everyone wants to go to bed at roughly the same time. Care staff may have to carry out laundry duties, and currently only a limited amount of activities are available as staff do not have the time to carry out more that the essential care needed. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 21 Sixty five percent of care staff have achieved an NVQ Level 2 or above in care, this helps staff deliver the same standard of care to people. Comments in the surveys returned were extremely positive regarding the staff, one person said “the staff are just wonderful and so helpful”. The recruitment process is managed centrally by City of York, though the manager interviews the prospective employee. The recruitment documents were in place, and there was written evidence that the police check was completed before the person started work, along with two written references. This helps to protect people from harm. Induction training has developed over the past twelve months, this is equivalent to Skills for Care and covers care practice issues and details of the skills needed for people to carry out their role One person confirmed that this takes place, a timescale of twelve weeks is set for this and mandatory training will be completed within this time. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 People who use this service experience good quality outcomes in this area. The home is run in the best interest of people living there, with health and safety needs being consistently met. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home is run in the best interest of the people living there. The manager is registered with the CSCI and has completed an NVQ Level 4 in management. The home has an open and transparent culture which the manager has fostered in the past two years. People using the service, visitors and staff all felt he was approachable and effective in running the home. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 23 People are able to express their views and opinions on a verbal basis to care staff, the deputy or the manager. Regular meetings take place and some auditing of the current systems is evident. There is no formal quality assurance system which covers the auditing of the care plans, medication system, meals provided or care delivered. Though the home have recently undergone a health and safety audit. This needs to be addressed through the City of York Council. People are able to keep ‘pocket money’ in the home. Individual wallets are available and a record of all transactions are made. Three wallets were inspected, on two occasions the money kept did not correspond with the records, this was only a small amount of money though the system needs to be more robust to ensure people are protected. This was discussed with the administrator who was aware that this needed to be addressed. Health and safety issues at the home were discussed. Currently City of York uses contractors for all health and safety checks and maintenance/repair work. There is discussion at this time about whether a maintenance person should be employed to service all the care homes. This would enable routine maintenance work to be done in a planned manner. Fire safety was discussed and clear records are available regarding weekly fire alarm testing, the fire risk assessment and the training staff have had regarding fire, moving and handling and first aid. Currently infection control training is given to new people through the induction process, this was felt to be sufficient. Individual training records are available and the deputy has worked hard to improve this system which now clearly identifies when training has taken place and when it is due. Details regarding water temperatures were inspected and these were found to be well maintained and within expected parameters. No issues regarding health and safety were identified and people spoken to confirmed they fell safe and happy in their environment. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x 2 x x 3 Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 Requirement All medication administered to people living in the home must be administered correctly and recorded and signed for on the medication administration charts. This will make sure that people receive their medications as prescribed There must be a system in place to make sure medicines with a limited number of days of use after opening have a date of opening recorded on the packaging and to identify and remove from stock any out of date medicines. This helps to reduce the risk of medication being administered that may no longer be safe to use. A robust quality assurance system needs to be implemented. This will ensure people’s views and opinions are sought and acted upon. Timescale for action 29/11/07 2. OP9 13 29/11/07 3. OP33 24 28/02/08 Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 26 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. 4. 5. Refer to Standard OP9 OP12 OP15 OP27 OP35 Good Practice Recommendations Regular stock balances of medication should take place. An audit of the medication charts should take place to identify if people are getting their prescribed medication. A review of the activities provided in the home needs to take place. A review of the meals provided at lunchtime needs to take place to ensure people like the food they are served. Staffing levels on a morning and evening needs to take place, staff need to have time to help with activities. The records pertaining to people’s pocket money need to be accurate and reflect the amount of money stored in the home. Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Haxby Hall - City of York Council DS0000034916.V333772.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!