Inspection on 22/08/07 for Holbeach Hospital

This inspection was carried out on 22nd August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Holbeach Hospital 17/06/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Holbeach Hospital Boston Road Holbeach Spalding Lincs PE12 8AQ Lead Inspector Julie Western Unannounced Inspection 22nd August 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holbeach Hospital DS0000002592.V341628.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.V341628.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.V341628.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 31st May 2006 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 was fully occupied. 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.V341628.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took into account any previous information held by CSCI including the home’s previous inspection reports, its service history, any preinspection questionnaires completed by the Manager and any residents’ questionnaires sent to the home by the Commission prior to the inspection. The site inspection was unannounced, took place over three hours and consisted of tracking a sample of residents’ care records and assessing the care given. Some policies and procedures were examined and some records concerning the safety of the home were also seen. One resident, three care and ancillary staff and two visitors were spoken with. The Manager was present throughout the inspection. At the time of the inspection the manager confirmed that the weekly fees ranged from £394- £448, depending on the assessed needs of the resident. Additional charges are made for services such as chiropody and hairdressing. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report is available in the manager’s office. What the service does well: People who live in this home are cared for by a well managed, trained and competent team of staff who meet their individual health and personal care needs in a sensitive manner. Residents spoken with all praised the staff group; one said ‘We’re very well looked after’ and a visitor compared the home very favourably with others his relative had lived in. A high level of up to date equipment is provided to enable the residents to receive safe care. Residents observed during this inspection were relaxed with some positive interactions with staff. The regular staff advisory group and health and safety meetings held by the home ensure that residents are safe from harm. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 6 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.V341628.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 Holbeach Hospital DS0000002592.V341628.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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the home is right for them. EVIDENCE: The manager confirmed that she or a trained nurse usually visited prospective residents at home or in a care setting such as a hospital to undertake a thorough assessment of all their care needs. For the Anne Waltham unit, GP referrals were made. Records confirmed this. Residents and visitors spoken with had received prior information such as the statement of purpose and service user guide before admission. One resident said that his relatives had chosen the home for him as he was too unwell at the time to make decisions. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 9 A visitor confirmed that he and his relative had visited the home for the day before moving in permanently. Written admission documentation was clear and gave staff the information needed to meet the residents’ needs. A staff member described the admission process and the importance of making new residents and their families feel welcomed. The home does not provide intermediate care [see standard 6]. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 10 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 good. This judgement has been made using available evidence including a visit to this service. The home’s records give a clear picture of the health and personal care needs of the residents and enable staff to meet these needs with sensitivity and regard for their privacy and dignity; care plans also need to reflect social and emotional needs. EVIDENCE: Care plans looked at were clear regarding medical details and personal health care needs and contained risk assessments, but lacked information on social histories and preferred activities. Regular reviews took place and most care plans were signed, showing the involvement of the residents and their supporters. Records showed that residents regularly saw their GP and, where necessary, consultant, opticians and dentists. A visitor said that his relative’s health had improved since admission to the home. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 11 The home has not had regular visits from a pharmacist for some years; following discussions, it was agreed that the manager would immediately contact local pharmacists for this service to be reinstated. The staff team were observed carrying out their duties with kindness and sensitivity, especially when attending to their personal needs and during mealtimes. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 There is a range of activities and events for residents to take part in, but these are not co-ordinated. Residents have a choice of meals from a varied and balanced menu. EVIDENCE: The home does not have a designated activities co-ordinator and there was no mention in care plans of social history, preferred activities, pastimes or daily routines. Residents spoken with said they enjoyed the events and activities; One resident described how a wedding blessing had been held at the home, which residents who wished to, had attended and thoroughly enjoyed. Regular activities included weekly bingo, exercise class and visits from outside entertainers. The home’s League of Friends recently opened a weekly shop where residents could buy sweets, magazines, cards and other items and this had proved to be very successful. Representatives of all church denominations in the area visited the home regularly. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 13 One resident described bus trips into the country with carers. Menus were balanced and varied, with a daily choice and a use of fresh fruit and vegetables. All residents praised the food; one resident said ‘it’s good and there’s always plenty.’ The cook was knowledgeable about the dietary needs of older people and kitchen staff had achieved national qualifications in catering. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 14 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. This judgement has been made using available evidence including a visit to this service. Information on complaints is clear and gives residents and their supporters the confidence that comments and complaints will be listened to. Residents are kept safe from harm by clear policies and procedures. EVIDENCE: Residents spoken with said they had no wish to complain but would go to the manager if they did. The complaints records showed that there had been no complaints since the last inspection. Procedures for safeguarding adults were comprehensive and up to date. Staff members spoken with said they had received training in safeguarding adults, which training records confirmed. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The residents live in a safe, comfortable and pleasant environment that is suitable for their needs. EVIDENCE: Externally, the building, which was purpose-built, was maintained to a high standard, with well-tended grounds and attractive, accessible garden and patio areas. The ongoing maintenance programme has included redecoration of bedrooms as they are vacated. Residents spoken with said they were very satisfied with the decoration and cleanliness of the home and how much they liked their bedrooms. Recent improvements have included the introduction of CCTV and the installation of a key press outside the back door, to improve safety. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 16 Recent purchases have included a new cooker and washing machine. There are a large number of hoists and pressure-relieving equipment, ensuring that residents are safely managed and well cared for. The home has recently purchased a new hoist. Staff members have received training and know how to use the equipment properly. Separate staff are employed for domestic and laundry services. Gloves and aprons are provided and the home has clear infection control policies. 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. The home was clean and pleasant-smelling throughout. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Staff numbers are in sufficient quantity for them to be able to care for the residents. Staff members are suitably trained, qualified and competent. EVIDENCE: The staff rotas showed that there were enough staff members to meet the needs of the residents. Staff members said they thought they had enough time to complete their tasks and residents confirmed this. Residents spoken with said the staff team was very good; a visitor said ‘they’re kind, patient and pleasant’. Two staff files were examined; they contained recruitment procedures, including criminal records and vulnerable adults checks. None of the staff files examined contained photographs. The most recent member of staff to be appointed described how she was interviewed, gave references and underwent an induction procedure. There is an extensive training programme for staff, which includes training in care, internal lectures and training from outside trainers. Staff members said the training had enabled them to improve the care and support for the residents. During conversation with the manager, it was agreed that staff members would benefit from training in managing challenging behaviour. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 18 The manager said that the staff group included Link nurses who have specialist training in palliative care, tissue viability and continence. Records showed that eleven staff members had achieved the National Vocational Qualification, a nationally recognised qualification, two were working towards the NVQ 2 in catering and one of the night care staff was a trained nurse. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 19 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): 31,33,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An open style of management helps the home run smoothly; the health, safety and welfare of the residents are promoted. The views of residents are listened and they are involved in decisions affecting them. EVIDENCE: The registered manager has been in post for over a year. She is a registered nurse and has s the registered manager’s award, a professional qualifications. Residents and staff members said that the manager was approachable and accessible. A visitor said ‘I have no complaints about the running of this home at all’. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 20 A positive approach to seeking the views of residents was seen and residents spoken with said they were constantly asked for their views on matters concerning the running of the home. Service user questionnaires had been sent to residents and their families to encourage them to give their views on improving the home. The most recent residents’ meeting was held in July 2006. The home has detailed policies and procedures; these need updating generally since most of them had not been updated since October 2005. The manager said that regular staff meetings had commenced and staff supervision took place regularly; records confirmed this. There were regular staff advisory group meetings att4ended 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.V341628.R01.S.doc Version 5.2 Page 21 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 2 8 3 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 X X X X X X 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 3 X 3 X X X X 3 Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? none 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 OP3 Regulation 14[1][a] Requirement Assessments must cover social interests, hobbies, religions and cultural needs, carer and family involvement and other social contacts/relationships to ensure that residents’ needs are met fully. Records of service users must include photographs for each resident. Timescale for action 26/10/07 2. OP37 17[1][a] 26/10/07 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 OP9 OP12 Good Practice Recommendations The home should seek information and advice from a pharmacist regarding medication policies within the home and medicines dispensed for individuals in the home. There should be a dedicated activities organiser, who, following an assessment of the social, emotional and spiritual needs of each resident, can develop a programme of activities suited to their individual needs. Staff records should contain up to date photographs of DS0000002592.V341628.R01.S.doc Version 5.2 Page 23 3. OP37 Holbeach Hospital 4. OP37 each staff member. Policies and procedures should be updated regularly. Holbeach Hospital DS0000002592.V341628.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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