CARE HOMES FOR OLDER PEOPLE
Haxby Hall - City of York Council Haxby Hall York Road Haxby York North Yorkshire YO32 3DX Lead Inspector
Denise Rouse Unannounced Inspection 22nd February 2006 09:25 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.V282931.R01.S.doc Version 5.1 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.V282931.R01.S.doc Version 5.1 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) City of York Council *** Post Vacant *** 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.V282931.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 31 August 2005. 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 who do not have any specialist requirements. 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. Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place over two hours thirty-five minutes and was carried out by one inspector, following a day’s preparation. The acting manager was present and assisted for the latter part of the inspection. A tour of the building was undertaken this included communal areas, bedrooms, laundry offices and sluice rooms. Service users and staff were spoken with. Records inspected included staff files and policies relating to adult protection. At the end of the inspection a feedback session was held with the acting manager and the regulatory inspector. What the service does well: What has improved since the last inspection?
The acting manager undertakes care duties as well as managerial duties. Night visits are undertaken to ensure that the standard of service is maintained at a constant level. Staff files are now stored at the home, this allows the acting manager and inspection team access to all relevant information regarding existing and new staff. This ensures that service users can be protected from staff that may not be suitable to work within a care home. All staff have access to information relating to the protection of vulnerable adults, The “ No secrets” information containing information relating to adult protection was available within the nurses office for all staff to access and read. Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 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. Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 7 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.V282931.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected. EVIDENCE: Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected. EVIDENCE: Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected. EVIDENCE: Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18 Service users are protected from abuse. EVIDENCE: All staff have access to a whistle blowing policy and procedure. Staff have been introduced to the “ No secrets” document, which gives vital information relating to adult abuse. This was accessible within the nurse’s station. All new staff are given training at induction relating to the Protection of Vulnerable adults. Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 26 Service users live in a home that appears to be generally well maintained, however there were shortfalls, which may place service users at risk. EVIDENCE: The home appeared clean and tidy. Alcohol hand wash, gloves and plastic aprons were available throughout the home. One bedroom had an unpleasant odour; this was discussed with the team leader who stated that this issue was being addressed. Access to the laundry was restricted by a locked door, however the outer laundry door was left open and unlocked when this area was not manned. Therefore security to this area could not be guaranteed as access could be gained via the garden. This door must be closed and locked when the laundry is unmanned. Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 13 Behind the washing machines an area of boxing over pipe work had been removed. This exposed area had become very dusty and there was an old toilet roll and a sheet of writing paper discarded next to the exposed pipes. The boxing must be reinstated once this area has been adequately cleaned. This will ensure that the area can be kept clean and therefore reduce the risk of cross infection or cross contamination. Sluicing of soiled linen appeared to be undertaken on two programmes of the washing machines. It was recorded that the sluice cycle was carried out for both of these programmes at 30 degrees centigrade. Sluicing must occur at 65 degrees centigrade for at least a ten-minute period to ensure that the items are fully sluiced and disinfected by the sluicing process. This must occur to prevent the risk of cross infection. Cleaning chemicals within the downstairs sluice could be accessed due to the sluice door being left unlocked. This must remain secured so that service users do not gain access to potentially harmful chemicals. The upstairs servery cupboards were inspected, dishwasher powder was found decanted into blue plastic beakers held under the sinks. This must be stored within the original packaging and held in a secure cupboard to prevent possible access to this potentially harmful chemical by service users. One pink carpet within an upstairs lounge dining area required cleaning, as food stains were apparent. This should be undertaken routinely to ensure this carpet remains clean. The laundry door and downstairs sluice door were seen to be held open during the inspection process by means of a wedge. This practice must cease immediately as it places service users and staff at risk. This was pointed out to the team leader, who immediately removed the wedges and discarded them. Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users are protected by the homes recruitment policies and procedure. EVIDENCE: Staff files were now available at the home and were stored securely. Staff files examined were seen to have had the necessary pre employment checks completed, including a criminal records bureau check and protection of vulnerable adults check. Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 31 Service users can be assured that the acting manager is fit to be in charge and demonstrates his commitment to the service users and staff, however he has not yet gained status as the registered manager. EVIDENCE: The home is run by an acting manager who is experienced and holds the National Vocational Qualification in Management at level 4. He has not yet been registered as the manager with the Commission for Social Care Inspection. This must be addressed immediately. Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 1 X X X X X X 1 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X X X X Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 23 Requirement The registered person must ensure; • The pink carpet in the lounge is cleaned. The registered person must ensure; • Dishwasher and cleaning chemicals are stored securely, preventing access by service users. • The external laundry door must remain locked shut when this area is unmanned. • Boxing behind the washers must be reinstated. • Washing machine sluicing cycles must be at 65 degrees for 10 minutes. • Laundry and sluice doors must not be held open by inappropriate means. The registered person must ensure that an application is made by the acting manager to be become registered with the Commission for Social Care
DS0000034916.V282931.R01.S.doc Timescale for action 22/02/06 2 OP26 23 & 13 (4) (c) 22/02/06 3 OP31 8 22/02/06 Haxby Hall - City of York Council Version 5.1 Page 18 Inspection. All necessary documentation and fees must be supplied. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Haxby Hall - City of York Council DS0000034916.V282931.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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