Inspection on 04/12/06 for Haxby Hall - City of York Council

This inspection was carried out on 4th December 2006.

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.

Other inspections for this house

Haxby Hall - City of York Council 22/02/06

Haxby Hall - City of York Council 31/08/05

Haxby Hall - City of York Council 10/11/04

Haxby Hall - City of York Council 12/08/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

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 4th December 2006 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.V319439.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.V319439.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) 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.V319439.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 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 fees per week are £426.92. 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.V319439.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection of this service took place on Monday 4th December 2006. One inspector spent 6.5 hours at the home. A pre-inspection questionnaire was completed and surveys were discussed and completed by service users during the visit. Four service users were case tracked, a relative was spoken to in detail and a range of service users and staff were chatted to during the day, this included the manager and deputy, the cook, care leaders, carers, and general assistants. Discussions took place regarding all twenty two key standards with the manager and deputy. It was evident from this that the home has the best interests of the service users and their families at heart, with a good standard of care being offered in a pleasant environment. What the service does well: What has improved since the last inspection? What they could do better: Service users are being put at risk because there are not enough staff to meet the needs of forty nine service users. Service users have a limited amount of activities offered to them, this is because there are insufficient staff to facilitate this. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 6 Medication is not being safely stored, which poses a risk to the home. Service users do not have their nutritional needs consistently assessed, which could potentially have a negative outcome for service users. Service users are at risk from scalds and burns through water temperatures being too high in certain parts of the home. Staff must ensure service users are not too cold when sitting in the upstairs lounge area. Some service users said the food served upstairs is not always hot enough. The room is not consistently clean, a robust system needs to be implemented to resolve this. 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.V319439.R01.S.doc Version 5.2 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.V319439.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable) Quality in this outcome area is good. All service users have their needs thoroughly assessed, this is further enhanced through a separate assessment by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users needs are fully assessed prior to admission. Four assessments were checked which had been completed by a care manager. Initial assessments are also carried out by the home manager prior to admission, this information was also documented. The assessments discuss social care needs, previous life history, medical information and specific needs of each individual. The manager feels it is important to involve both the service user and their family when initial contact is made, this makes the move to the home easier for all concerned. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. Whilst the standard of care is good, improvements are needed regarding nutrition and medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users discussed the good standard of care they receive. Four service users chatted about their key workers, personal care and how their privacy and dignity is maintained. Care plans were in place which were reviewed and evaluated on a regular basis. Risk assessments for moving and handling, and prevention of pressure sores were in place. Staff had a good understanding of how to meet individual needs, though due to poor staffing levels they felt they could not spend as much time with each service user as they would like to. Care plans clearly identified the specific need and new documentation has recently been introduced which is user friendly and easy to understand. Service users were observed in the lounge and dining areas, some ladies had visited the hairdresser, and everyone looked smartly dressed and well cared for. One man said ‘I have everything I need here’, another lady said ‘I am well cared for, staff really look after me’. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 10 In the care plans service users likes and dislikes regarding food and drink was discussed, though no specific nutritional plan was in place. This would be beneficial to identify if anyone is underweight or overweight or needs specialist advice from the community dietician or GP. The manager was aware that this needed to be introduced and already has links with the GP and has had discussions with other staff regarding nutritional assessments. The home has a good relationship with the District Nurses. One lady who had a weekly dressing confirmed she sees the nurse on a regular basis, another service user said she gets a visit from the chiropodist. The home is aware of how to access a range of healthcare professionals. The accident book is completed and the home completes regulation 37 notifications for incidents that occur regarding service users. Throughout the visit privacy and dignity was generally maintained, on one occasion only, a member of staff spoke to a service user from across the dining room. The member of staff should have gone up to the service user to talk to her. Staff were observed knocking on doors prior to entering, and addressing service users in an appropriate manner. The medication system was inspected, medication charts were up to date and staff had a good understanding of the specific medication for each service user. Fridge temperatures are taken daily and medication training is offered. A medication round was observed and this was carried out appropriately. It was evident that the medication trolley was stored temporarily in the care leaders office, this was not secured to the wall and controlled drugs were left on top of the trolley. A blister pack of medication was on the table and the key for the room was next to the door, which would potentially give access to anyone entering the home. The room where the medication trolleys are normally stored is also accessed by the maintenance person, this room was 23.5 degrees centigrade, and had non-clinical items stored in here. The manager was made aware of these issues and took immediate action to rectify this. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. Service users are encouraged to be autonomous and independent, more activities are needed and whilst the food served is adequate some improvements could be made in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were observed enjoying a ‘sherry and mince pie’ afternoon during the inspection. The home had organised for employees of York University and local banks to come and spend their lunch hour with the service users. A Christmas outing is planned for all service users and when the staff have time they play dominoes and cards and chat to individuals. Currently there is no specific activities organiser, this is done on an ‘adhoc’ basis. One service user said she likes to play dominoes and watch television. Large print books are available which were in use. All staff spoken with said they do not have the time on an afternoon or evening to do anymore than basic care needs. This was discussed with the manager who was aware of this issue. Staff encourage autonomy and choice, visitors can come and go when they want, this was confirmed in the visitors book. Religious needs are catered for, this is recorded in the care plan. One person was Church of Scotland, one lady was a Jehovah’s Witness and this had been discussed as to how these needs Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 12 could be met. Daily routines were discussed and whilst staff spoken with said service users can choose when they get up and go to bed, this is dependant on having enough staff. Mealtimes in the home were examined. The meals are generally provided by the hospital, service users were observed enjoying these, both downstairs and upstairs. It was evident upstairs that the two staff serving lunches did not know the service users, many service users were given food they didn’t order. Four service users said the food was not hot, this was also confirmed by a relative. One lady said her porridge was ‘stone cold’ at breakfast time. Service users are offered a home cooked Sunday lunch every fortnight. The food available at the visit looked appetising though comments were made regarding the frozen vegetables and processed potato. The cook was spoken to who was aware of how to fortify food and ensure it was nutritious, though this is not always possible with the hospital food. This is an issue that needs to be taken up by City of York Council. The home have a range of dining areas which meet the needs of the service users. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. Service users have their views listened to and they feel safe and protected in this environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home have a complaints procedure in place, no complaints have been received by CSCI. All service users spoken with confirmed that if they had any issues they would be happy to discuss these with the staff, and manager of the home. Staff discussed adult protection and the action they would take if an allegation of abuse was made. The home have a multi-agency vulnerable adults procedure which the manager is aware of. Care staff spoken with discussed the ‘no-secrets’ document and what whistle-blowing was. Service users had a good rapport with staff and confirmed they felt safe in the home. Moving and handling practices were observed and these were carried out in a respectful manner. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. The environment is generally pleasant and well maintained, though aspects of hygiene could be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are cared for in an environment with plenty of communal areas. Maintenance is carried out by City of York Council. The home were in the process of altering the entrance area to make it more accessible for wheelchair users. Service users generally liked their own rooms and felt the lounge and dining areas were comfortable and pleasant. One lady did say she felt cold in the upstairs lounge, the radiator was not on and the room temperature was taken (this was 20 degrees centigrade, the optimum is around twenty one degrees centigrade). This was discussed with the manager. It was evident that some areas of the home could have been cleaner, for example many surfaces were dusty and had crumbs on. In discussion with the general assistants it was apparent that no structured system for cleaning and Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 15 laundering clothes is in place. The laundry was inspected and this had two washing machines and two driers. Staff were aware of infection control procedures and had completed this training. Gloves and protective aprons were used and red bags were used for soiled clothes. Service users were wearing clean and well ironed clothes, they confirmed that clothes are taken from their room, washed and ironed and returned. Handwashing areas were evident which staff were utilising. The manager did discuss the new system which is going to be implemented regarding hygiene in the home. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. Service users are being put at risk because there are not enough staff to meet their needs. However, the staff that are employed have received a range of training which makes them safe and competent to carry out their role. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Currently the home has forty nine service users, of these fifteen are highly dependant. This means that often two carers are needed to look after them. The home does not have enough staff to meet everyone’s needs. On an afternoon and evening there are three care staff and up to two care leaders (responsible for administering medication, documentation and overseeing care practices). When there are five staff this is approximately one member of staff for up to ten service users, if two of the three care staff are needed for one person this then leaves one carer to look after the other forty eight service users. This needs to be addressed urgently. This was commented on by service users and staff. Service users said sometimes they have to wait to go to bed, or they ring their bell at it is a long time until it is answered. Overnight there are three staff, again this needs to be reviewed. The staff in the home are extremely competent in caring for the service users, sixty five percent of care staff have completed an NVQ Level 2 or equivalent in care, this ensure that a consistent standard of care is maintained. The home have worked hard in achieving this and must be commended on this. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 17 Staff undertake induction training when they are first employed. A new system has recently been introduced which includes completion of mandatory training within the first six weeks of being employed. Files were checked and this confirmed that this training (known as Skills for Care) takes place. Staff also confirmed they had been inducted. The recruitment procedure of the home was inspected. Staff can only start work when the service have obtained two written references, a police check and a protection of vulnerable adults check. This was evident in discussions with the manager and when checking staff files. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. Service users best interests are paramount and then can express their views and opinions, however some service users are being put at risk because hot water temperatures are too high. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home has achieved an NVQ Level 4 and is registered with the CSCI. He has been at the home for approximately four teen months and is a valuable asset to the home. Many complimentary comments were made regarding the effective style of management, and he is supported by a deputy who is aware of the need for constant improvement and development of the service which will have a positive effect on the outcome s for service users. Quality assurance in the home has been developed. Monthly residents meetings take place along with staff meetings. A questionnaire is included in Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 19 some care plans for service users to share their views and opinions, staff discuss issues on an informal basis and audits are undertaken on care plans, medication and accidents. Prompt action is taken by the manager if any concerns are raised. Views of relatives are sought and the family are included in discussions regarding care practices and meeting needs of their relative. Finances were discussed, a pocket money account is available for service users. This was confirmed by four service users, this system is in operation throughout the City of York Council Homes. No concerns were raised. Health and safety was discussed. Staff receive mandatory training which includes fire, moving and handling, infection control, first aid and control of substances hazardous to health. Records confirmed this was the case. A range of certificates were highlighted on the pre-inspection questionnaire and during the visit emergency lighting, door closures and aspects of safety were identified. Fire alarm testing takes place weekly and staff are aware of this procedure. The water temperatures were tested and three were found to be too high (48-49 degrees centigrade). This was discussed with the manager and was acted upon immediately. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 20 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 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 1 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 1 Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 21 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 Medication issues :Timescale for action 05/12/06 2. OP15 16 3. OP26 16 4. OP27 18 a)The room for storing medication must not be used for non clinical purposes. b)The temperature of the room must be within the safe temperature for storing medication c)Medication trolleys when not in use must be properly secured in the designated area d)All medication must be stored correctly and not left on view in the care leaders office A review of the temperature of 11/12/06 the meals served upstairs must take place Staff serving meals upstairs must be aware of the food that is ordered and who the service users are. A robust cleaning system must 18/12/06 be put in place to ensure all aspects of the home are cleaned routinely in a thorough manner. Service users are being put at 18/12/06 risk because there are not enough staff, therefore a review DS0000034916.V319439.R01.S.doc Version 5.2 Page 22 Haxby Hall - City of York Council 5. OP38 13 of the staffing levels must take place particularly in respect of the fifteen service users with high dependency needs. Service users must not be put at risk of scalds and burns from water temperatures being too high. Three areas need to be adjusted: a)Toilet upstairs-near lounge. b)Bath upstairs (room 45) c)Bath downstairs (near toilet 5) 06/12/06 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. Refer to Standard OP12 OP15 Good Practice Recommendations A review of the activities provided in the home needs to take place. All service users should have all aspects of nutrition discussed and recorded, using an appropriate assessment tool. Haxby Hall - City of York Council DS0000034916.V319439.R01.S.doc Version 5.2 Page 23 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.V319439.R01.S.doc Version 5.2 Page 24 - 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. 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