This inspection was carried out on 31st August 2005.
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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
CARE HOMES FOR OLDER PEOPLE
Haxby Hall - City of York Council York Road Haxby York YO32 3DX Lead Inspector
David Martin Unannounced 31 August 2005 10:00 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 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 J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Haxby Hall Address York Road Haxby York North Yorkshire YO32 3DX 01904 768944 01904 766289 EPHhaxby@york.gov.uk City of York Council Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) N/A 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 J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 10/11/05 Brief Description of the Service: Haxby Hall is a care run by City of York Council and is registered to provide a service for 49 older people of either gender aged over 65 years who do not have any specialist requirements. The home was purpose-built approximately 35 years ago and is located just of the main street in Haxby. The home is only a short distance away from the village amenities. There is 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 J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out on 31 August 2005. It was unannounced and took 7 hours to complete. The majority of time was spent within with the service users in the home at the time of the inspection and with the staff on duty. There were opportunities to have discussions and observe staff interaction with the service users. A sample of service user files was examined and a check was made as to whether the home had complied with recommendations from the last inspection. Written and verbal feedback was given at the end of the inspection to the registered manager. What the service does well: What has improved since the last inspection? 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 J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Haxby Hall - City of York Council J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 7 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 standard(s) 3 & 6 Prospective service users have sufficient information about the home to make a positive choice about moving in. EVIDENCE: Some service users were able to confirm that they had visited the home prior to admission and had made a positive choice in moving to Haxby Hall. The case file of the service user most recently admitted to the home was inspected. This provided evidence that an assessment and personal information about the service user had been provided to the home by the care manager. Where possible, prospective service users are expected to spend a day in the home prior to admission as part of the assessment process. Intermediate care is not provided. Haxby Hall - City of York Council J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 8 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 standard(s) 7 - 10 Service Users’ health and social care needs are met. EVIDENCE: A sample of service user plans was inspected. They provided background information and a description of the day-to-day task that service users can accomplish and those where some assistance is required. New and improved care plans are being introduced and should be completed for all service users within the next three or four months. All service users are registered with a GP of their choice and are able to see other health care professionals as the need arises. This was confirmed by service users and evidence was also available in case files. The systems for the administration of medication were inspected and were found to be satisfactory. Haxby Hall - City of York Council J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 9 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 standard(s) 12 - 15 Service users are able to follow a lifestyle that suits their individual needs and they are able to maintain social contacts. EVIDENCE: Service users said they were pleased with the services offered at Haxby hall and that the standard of care met their expectations. The service users said they would like additional activities and the manager confirmed that this is an area where improvements can be made. They said that they are able to see their relatives and friends and can choose whether or not to be involved in any organised activities. The service users said that the food was good. Observation of the lunchtime meal provided evidence that meal was wellpresented and seemed to be enjoyed by service users. Haxby Hall - City of York Council J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 10 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 standard(s) 16 & 18 On the whole, service users are protected from abuse and their right to complain is upheld. EVIDENCE: Service users have been provided with the home’s complaints leaflet. In discussion, service users said they had no complaints to make about the quality of service in the home. They were clear about raising their concerns if they needed to. One minor complaint has been recorded since the last inspection and it has been resolved appropriately. The home has a copy of the latest version of the multi-agency procedures for the protection of vulnerable adults (POVA). Staff said they had received training in safeguarding older people as part of NVQ courses. They understood the need to report any concerns. To assist staff in understanding adult protection they should be provided with a copy of ‘No Secrets’. Haxby Hall - City of York Council J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 11 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 standard(s) 19 & 26 On the whole, service users live in a home which is well-maintained. EVIDENCE: Service users’ bedrooms are comfortably furnished and have been decorated with personal items such as photographs and ornaments. There are numerous sitting rooms and dining rooms which are maintained in good order. Two issues requiring attention were identified; the carpet in the main lounge requires cleaning; some hazardous products were stored in an unlocked cupboard in a service users’ kitchen. A new call bell system has been installed since the last inspection. Haxby Hall - City of York Council J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 12 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 - 30 Service Users’ needs are met by adequate numbers of staff, but new staff are not vetted properly EVIDENCE: There are adequate numbers of staff on duty. Agency staff are employed to cover sickness and vacancies. Staff confirmed that some vacancies had been recently filled and that there are enough staff on each shift. The manager confirmed that new starters are cleared through the Criminal Records Bureau or POVA but there was no written confirmation of this because the staff records are not maintained in the home. This has been a longstanding issue and is yet to be resolved by the City of York in this particular home. Haxby Hall - City of York Council J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 13 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 & 38 Service users live in a home which serves their best interests. EVIDENCE: The home has recently undergone a change in management. The new manager is not registered and no application has been yet been received by CSCI. A sample of the monies held on behalf of service users’ was checked against the records and was found to tally. A sample of records relating to the ongoing safety of the premises was checked and found to be up-to-date. Haxby Hall - City of York Council J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 14 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 1 x x x x x x 1 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 3 x x 3 Haxby Hall - City of York Council J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 15 Yes Are there any outstanding requirements from the last inspection? 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 17 Regulation 29 Timescale for action Staff records must be maintained 31/10/05 in the home. (This requirement has been outstsanding since 2002). The carpet in the main lounge 15/10/05 should be cleaned. All hazardous product should be 15/09/05 stored securely. Requirement 2. 3. 19 26 23 13 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. Refer to Standard 18 Good Practice Recommendations Staff should be familiar with No Secrets. Haxby Hall - City of York Council J53-J04 S34916 Haxby Hall V235779 280605 Stage 4.doc Version 1.40 Page 16 Commission for Social Care Inspection 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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