Inspection on 17/06/08 for Holbeach Hospital

This inspection was carried out on 17th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Holbeach Hospital 22/08/07

Holbeach Hospital 31/05/06

Holbeach Hospital 07/11/05

Holbeach Hospital 04/05/05

Holbeach Hospital 25/01/05

Holbeach Hospital 08/09/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Holbeach Hospital Boston Road Holbeach Spalding Lincs PE12 8AQ Lead Inspector Tobias Payne Unannounced Inspection 17th June 2008 08:55 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 Holbeach Hospital DS0000002592.V366446.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. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holbeach Hospital Address Boston Road Holbeach Spalding Lincs PE12 8AQ 01406 422283 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) manager@holbeach-hospital.org.uk Holbeach & East Elloe Hospital Trust Mrs Judith Ingham Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46), Physical disability (2) of places Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Anne Waltham Unit may care for service users requiring nursing or personal care over the age of 65 years who do not fall into any other category. In addition, this unit may care for one service user with a physical disability over the age of 61 years. The maximum number of service users to be accommodated in The Anne Waltham Unit is 9. The main house may care for users requiring nursing or personal care over the age of 65 years who do not fall into any other category. In addition, this unit may care for one service user with a physical disability over the age of 61 years The maximum number of service users to be accommodated in the main house is 37. The total number of service users to be accommodated in Holbeach Hospital is 46. 22nd August 2007 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Holbeach Hospital is a care home for nursing and personal care that has been converted from a hospital and has been managed by the Holbeach and East Elloe Hospital Trust since 1989. The main building comprises an out patients department, physiotherapy, a General Practitioner 9 bedded facility (The Anne Waltham Unit) of which there are 7 beds for the use of local GP’s, 2 care beds together with 37 additional care home beds. On the day of the inspection the home there were 30 people living in the home. The home is a two-storey building set in its own grounds with garden and patio areas. It is one mile from the town of Holbeach where there are shops and community facilities available. Accommodation is provided on ground and first floors. The first floor is served by a shaft and stair lift. There is parking at the front of the home. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 5 The fees charged by the home for care support on the 17/6/2008 ranged from £3981 to £460 each week. Extra charges are made for hairdressing, which ranged from £4.50 to £25 and chiropody, which was £6. Additional charges were for personal newspapers/magazines and personal toiletries. Information about the home including the statement of purpose, service user’s guide and copy of this report can be obtained from the manager. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection was unannounced and started at 8.55 a.m. It was done using a review of all the information available to us about Holbeach Hospital Care Home. The inspection visit took place over 6 hours. We also spoke with 19 people living in the home and 4 visitors to the home. We spoke with 5 staff members and the manager. The main method of inspection used on our visit was called “case tracking”. This involved selecting 2 people who live at the home and tracking the care they received through the checking of records, discussion with them, the care team and observation of their care. The commission is trying to improve the way we engage with people who use the service, so that, we can gain a real understanding of their views and experience of social care services. We are currently using a method of working where a person who has used care services in the past accompanies the inspector during the actual visit. We call this person an Expert by Experience. The person is an important part of the inspection team and helped the inspector to get a picture of what it is like to live in the home by talking to people about the outcomes they experience for themselves. The Expert by Experience spoke with 13 people living in the home on their own, contributed to the inspection process and provided a separate report. The comments received and observations made are reflected in this report. During our visit we also looked at records, spoke to staff, the people who lived in the home and one visitor and walked around the home. What the service does well: People living in the home told us they were very well cared for by a committed and competent care team. They were very satisfied with the care, approach of staff and the overall service provided by the home. The management take care to ensure that each persons needs are assessed before entering the home. People told us they enjoy their food, which is fresh, varied, well presented and nutritious using fresh ingredients. There was a programme of education and training provided for the staff. People also told us that they are cared for by a team of staff who meet their individual health and personal care needs in a sensitive manner. A high level of up to date equipment is provided to enable the people living in the home to receive care. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Holbeach Hospital DS0000002592.V366446.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 Holbeach Hospital DS0000002592.V366446.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): Standards 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is information to enable people to make a decision about whether or not to come into the home. People coming into the home receive an assessment and information about how their needs will be met. . EVIDENCE: There was a clear service user’s guide and statement of purpose available during our visit. We observed that the address of the commission referred to our Lincoln office. The manager agreed to take action to update the information and a recommendation is made in the report for this to be changed to refer to our Cambridge office. The manager told us that when a person asks to move into the home they are assessed using a pre-admission assessment form. Information was available to show that the manager does this assessment to make sure each persons physical needs can be met before they move in. Some information was available to show that doctors also support people in their request to move into Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 10 the home by making contact with the home to support the overall admission process. The manager told us that the care team speak to people about what to expect when they move into the home and take time to listen to people and answer any questions they may have. Following these discussions written confirmation is be sent to the person confirming the home is able to meet the needs identified on admission. Each person also had a detailed contract outlining the cost of the stay. The home does not provide intermediate care. Holbeach Hospital DS0000002592.V366446.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): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service are happy with the care and support they receive. However, Care plans do not reflect all the current needs of people or show their choices and preferences. The lack of effective care planning puts people at risk. People are supported to take their medication in a safe way. EVIDENCE: Each person had a care plan. This included a photograph of the person. Care records included details of their assessment at the time the person moved into the home, care plan, moving and handling and risk assessment. In addition, there was information about the person, brief details of activities of daily living, medication, records of GP and other professionals, monthly weight and nutritional assessments. We looked in depth at 3 care plans. They showed inconsistency in that 2 did not show any evidence that the people had been fully involved in identifying their care and support needs within the actual care plan. Some care plans did Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 12 not provide sufficient details about what care and support staff should carry out if they had concerns about a person’s personal care or if needs change. Information was available to show that reviews of peoples care needs took place. There was however, little evidence to show that the people were involved in their reviews. The record system used gives provision to obtain the signature of the service user or their advocate as agreement to the care plan. One did have this and was dated but did not have a staff signature. The other 2 were dated and signed by staff but not by the person. Records did not show any evidence of choice and did not show the peoples preferences. People who needed to be supported in bed were looked after in specialist beds and made comfortable and treated and cared for in a dignified manner. During our inspection a pharmacy visit was taking place as an agreement had made with Lincolnshire Teaching Primary NHS Trust to provide a pharmacy service. We were told about how records were well maintained and how they were well managed. When people need support to take their medicines registered nurses assist with this and the manager told us that staff are assessed before they are considered competent to do this. We saw staff giving medication in a professional manner identifying the person, giving the medication and signing that it had been given. Staff were vigilant in the lounges and available if needed. All the people and visitors we spoke were very complimentary about the care and approach of the staff. One person told us “Oh it is wonderful. Everyone is so kind and so caring”. The carer we heard replied to the person “it’s a pleasure”. Staff attended to each person in a calm and sensitive manner promptly. We saw call bells promptly attended to. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are encouraged and supported to make choices to take part in a variety of social activities. However, these activities may not suit all the people. People choose from and enjoy a well-balanced nutritious diet, which suits their needs. EVIDENCE: A range of activities was provided. This included a bingo session provided by the League of Friends of Holbeach Hospital. On Thursday there is movement to music provided by an outside person and visits by outside entertainers. There is a monthly interdenominational church service in the home and arrangement can be made for other religious needs to be catered for. Details of their interests are obtained on admission and they are encouraged to maintain these interests. We saw one person in bed happily involved in an activity, which she wanted. There were well-tended garden areas with accessible patio areas. The manager told us that the staff team support people to take part in activities but that no individual staff member had responsibility for organising or planning activities with people. There was also no activities programme. We Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 14 have recommended in the report that the manager obtains the views of the people living in the home about the range of activities they want to see so that they are more fully involved and given more choice. Visitors were welcomed to the home and we spoke to one visitor who was very complimentary about the home and said, “I can visit whenever I wish to do so”, “I always receive a warm friendly welcome, the staff are wonderful and I am kept fully informed”. People who live in the home told us that were satisfied with the meals and catering service. The home received an inspection by the Environmental Health Officer for South Holland District Council on the 8/3/2008. As a result it was awarded 3 tulips (excellent). We saw food being served from hot trolleys in each of the 3 dining rooms. We saw staff sitting with people who needed assistance doing this in an unhurried and sensitive manner. We saw staff taking care to serve the food. Comments were, “I have had a very enjoyable lunch” and “if I do not like something the staff will find an alternative.” Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People know how to make a complaint and feel that staff will listen to their views. The care team know how to respond to a complaint. EVIDENCE: There was a detailed complaints procedure in the statement of purpose and service user’s guide. No complaints had been received by the manager or us. A complaints register was being kept. None of the people or staff had any complaints about the home. We spoke to a member of staff who knew what abuse was and what she would do if abuse were suspected. The home had a copy of Lincolnshire’s Adult Protection Procedures. We had been made aware of a safe guarding adult’s issue, which is being investigated by Lincolnshire County Council but is not yet concluded. The manager has been co-operating throughout this investigation. People told us that they felt they could approach staff if they had any concerns or worries. Comments we received included “I have no concerns” and “I can always talk to the staff if I have any worries”. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 16 Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 17 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): Standards 19, 20, 21, 22, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, comfortable and pleasant environment that is suitable for their needs. EVIDENCE: During our visit we saw that the home was clean and fresh throughout. There was a decoration programme and since the last inspection some of the bedrooms had been painted, new sink tops provided on the vanity sink units in the bedrooms and a conversion from a bathroom to shower room was being completed. In addition 3 new pressure-relieving mattresses had been purchased to complement the variety of moving and handling equipment, pressure relieving mattresses and special beds already in the home. Staff had received training and knew how to use the equipment properly. Separate staff were employed for domestic and laundry services. Gloves and aprons were provided and the home has clear infection control policies and Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 18 alcohol hand wash dispensers throughout the home. There is a large laundry in the grounds of the home, with sluice cycles on both of the commercial washing machines. There are two commercial tumble dryers. There are enclosed sluices on both floors. People who were sat in the 3 lounges of the home had their own belongings with them at side tables as well as in their bedrooms. The lounges each had new large flat screen televisions and there were background music facilities. Those in bed had over bed table enabling them to have access to drinks, tissues, fruit, newspapers or books or the television control. Everyone commented on how clean, tidy and odour free the home was. Alcohol hand dispensers had been provided at the front of the home. Comments we received included “she says the home is always fresh and clean” and “I like my room”. We again received no negative comments. There are large well-tended gardens with patio space with benches, tables and parasols where people could sit out in pleasant weather. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 19 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): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a safely recruited, trained staff team available who are able to meet the needs of the people living in the home. EVIDENCE: Everyone we spoke with felt there were sufficient levels of staff to meet their needs. Staff went about their work in a professional but informal manner. They spoke about, ”working as one team”. Each person was recruited correctly. We looked at the files for 2 staff. These showed separate folders for each person with an application form, job description, Criminal Records Bureau check, 2 references obtained, terms and conditions. The duty rota showed across the 24-hour period that there were 2 registered nurses staff working in the home. The manager told us that the shifts are flexible to suit family needs. In addition there were separate staff for domestic, laundry, catering, administration, gardening and maintenance. We were told that all the care staff had either obtained or were studying for a qualification in care (National Vocational Qualifications). In addition, 4 staff members also had NVQ level 3. Staff training had included end of life in care homes, HIV aids, catheterisation, handling of medicines, infection control, moving and handling, the Mental Capacity Act 2005, death Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 20 and dignity and record keeping. Future training had been arranged for clinical supervision, advocacy, the Mental Capacity Act 2005 and understanding and managing challenging behaviour. The home also employs nurses who act as Link nurses and have specialist training in palliative care, tissue viability and continence. They meet with the Lincolnshire Teaching Primary NHS Trust and other nurses to share practice. We had no negative comments from staff, visitors or any of the people living in the home. Comments included, “whenever I need any help the staff are there”. Staff commented, “We work together and I enjoy working here”. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 21 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): Standards 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management record systems are inconsistent and do not show that in all cases how peoples health; welfare, safety and choices are promoted. The management needs to ensure that people, relatives and professional visitors have the opportunity to voice their views and opinions and use feedback from questionnaires to make improvements. Policies and procedures need to be reviewed and updated to reflect changes in practice and to make sure peoples needs are fully met. EVIDENCE: The registered manager is a registered nurse and has the registered manager’s award and other professional qualifications. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 22 All of the people living in the home, visitors and staff told us that they could approach the manager or staff if they had any concerns. A visitor said ‘I have no complaints about the running of this home at all’. The homes’ policies and procedures had a section on quality assurance and this showed how a specific subject would be chosen each month to audit. In addition, the manager told us there was an annual survey sent out the people in the home to learn of their views as well as residents meeting and a quality circle. However, the manager was unable to tell us when the last survey was and had no quality assurance system in place to monitor and continue to improve the actual care and outcomes for people who live at the home. We talked to the manager and the homes board of directors about how this lack of audit could affect the overall quality of the care and support provided. The manager and director agreed to take action to undertake a review of the current arrangements to make sure people were more fully supported to express their views about how the home can improve. There were policies and procedures available for staff to use when providing care, which were clear and detailed but last reviewed in 2003. There were clinical procedures available but the information was dated 2000. We were also told that the manager does not currently have an equality and diversity policy. We talked to the manager about this and she agreed to make sure an equality and diversity policy is introduced and staff made aware of this important aspect of care. Some people who live at the home needed additional support with their finances. Where this was the case we saw that it was well organised with clear records and receipts. We were told by the manager that staff supervision is being introduced and further training is to be provided to ensure that staff who will carry this out have the correct skills. There were staff meetings and regular staff advisory group meetings attended by the manager and the chairman of the Trust, regular health and safety meetings and the home also received monthly, unannounced visits from members of the Trust. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 23 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 2 X Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 24 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 Regulation 15 Requirement The manager must ensure that all care records including care plans have been produced wherever possible with the involvement of each person and/or their relative or advocate. In addition regular reviews must take place of the care plan with the involvement wherever possible of each person and/or their relative or advocate. Signatures of the person must wherever possible be obtained to confirm this. Timescale for action 17/08/08 2. OP37 OP12 16(n) Staff responsible for writing in care plans should also be reminded that they are personally accountable for maintaining clear and accurate records as they reflect the care and support which is given to the person receiving the care. This will ensure that all care plans include the preferences of each person and reflect their needs. The manager must obtain the 17/09/08 views of the people living in the home about the range and type of social activities they want to DS0000002592.V366446.R01.S.doc Version 5.2 Page 25 Holbeach Hospital 3 OP33 24 see in the home. This will ensure that the activities provided are what the people want. The manager and provider must establish and maintain a system for evaluating the quality of care and services in the home. This should include introducing regular audits of care records, medication and care practice. Action plans should be introduced where shortcomings have been identified. This will ensure that the home provides a good quality of service and practice. 17/09/08 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 Refer to Standard OP9 Good Practice Recommendations The manager should obtain a copy of an up to date British National Formulary and a copy of the Royal Pharmaceutical Society of Great Britain’s The handling of Medicines in Social Care. This to ensure that good up to date practice is carried out in medication practices in the home. The manager should ensure that any reference to our old Lincoln address in the statement of purpose, service user’s guide and complaints procedure is replaced with our Cambridge address. The manager and provider should ensure that the home’s adult abuse policy and procedure makes reference to contacting Lincolnshire County Council’s safeguarding adults team instead of ourselves, as they are the lead authority in these issues. The manager should ensure that clinical procedures used in the home are up to date and an up to date copy of the information used is obtained. The manager should also ensure that registered nurses are aware of these resources to ensure their clinical practice is kept up to date. DS0000002592.V366446.R01.S.doc Version 5.2 Page 26 2. OP16 3. OP12 OP18 4 OP33 Holbeach Hospital 5 OP37 The manager and provider should produce an equality and diversity policy and ensure that staff are aware of issues about promoting equality and diversity and ensuring that they know about how to ensure that the diverse needs and human rights of people in the home can be met at all times. Holbeach Hospital DS0000002592.V366446.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Holbeach Hospital DS0000002592.V366446.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!