Inspection on 31/05/06 for Holbeach Hospital

This inspection was carried out on 31st May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 22/08/07

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 Mr Toby Payne Key Unannounced Inspection 31st May 2006 08:20 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.V288157.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 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 Jean Garner Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The care home is registered to provide nursing and personal care for service users of both sexes whose primary needs fall within following categories: Old age, not falling within any other category (OP) up to 38. This to include up to 8 beds for personal care. In addition one bed (PD) physical disorder for one named person 56 years and over in Holbeach Hospital Care Home. The category of OP applies to service users who are over 65 of age. The category of PD applies to one physical disability place for a named individual aged 56 . THE ANNE WALTHAM UNIT is registered to provide nursing and personal care for service users of both sexes whose primary needs fall within the following categories: Physical disability (PD) aged 45 years and over and old age, not falling within any other category of OP The category of OP applies to service users who are over 65 years of age. The category of PD applies to physical disability for service users who are over 45 years of age. THE MAXIMUM NUMBER OF SERVICE USERS TO BE ACCOMMODATED IS 37 IN HOLBEACH HOSPITAL AND 9 BEDS IN THE ANNE WALTHAM UNIT. THE NUMBER OF BEDS REGISTERED IS 46. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 5 Date of last inspection 7th November 2005 Brief Description of the Service: Holbeach Hospital is a care home providing nursing and personal care only. The home is a converted hospital and is managed by the Holbeach and East Elloe Hospital Trust. The Trust celebrated its 15th year of operation in 2004. The main building of which the home is part, comprises an out patients department, physiotherapy, a General Practitioner 9 bedded facility (The Anne Waltham Unit) of which there are 7 GP beds, 2 care beds together with 37 additional care home beds. On the day of the inspection there were no empty beds. The home is a twostorey building set in its own grounds with garden and patio areas. Accommodation is provided on ground and first floors. The first floor is served by a shaft and stair lift. There is parking available at the front of the home. The home is one mile from the town of Holbeach where there are shops and community facilities available. The fees at the inspection on the 31/5/2006 ranged from £379 to £415 per week. Extras are for hairdressing which range from £4.50 to £20, chiropody £6, toiletries, personal newspapers and magazines. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This visit was part of the key inspection, was unannounced and started at 8.20 am and took place over 6½ hours. It was undertaken using a review of all the information available to the inspector regarding our information about Holbeach Hospital. The inspector spoke to 9 residents, one visitor, 7 staff, and the acting manager. The main method of the inspection was called “case tracking”. This involved selecting 2 residents and tracking the care they received through the checking of records, discussion with them, the care staff and observation of how their care was delivered. The inspector also observed how care was delivered and how staff responded to other residents living in the home. A pre-inspection questionnaire was completed by the home and 12 comment cards were also received. What the service does well: What has improved since the last inspection? The acting manager has achieved a management qualification. Three bedrooms have been redecorated, new wash basins have been installed in 3 bedrooms and a number of windows have been replaced. Improvements have been made to the hairdressing room. A large plasma television has been provided in day room one in the main home. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 7 Three new profile beds to enable staff to care for residents safely have been purchased and 4 new overlay mattresses provided. 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. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 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.V288157.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Residents receive information to enable them to make a choice as to whether or not they wish to come to this home. Holbeach Hospital Care Home meets the needs of residents coming into the home. EVIDENCE: There is a detailed statement of purpose and service user’s guide. A copy of the service user’s guide is given to each person when being admitted to the home. There are separate guides for both the nursing home and the Anne Waltham Unit. Each person is assessed before entering the home and written confirmation is sent to them confirming that the home can meet their assessed needs. There was also evidence to show that each resident receives a contract/statement of terms and conditions. The home does not provide intermediate care. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. There is good care planning in this home. The health and welfare needs of the people living in his home are fully met. Resident’s dignity is also met. Medication is correctly administered. EVIDENCE: All residents had detailed and up to date care plans. These described their health and welfare needs. Records outlined their assessment needs, personal needs, doctor’s notes, care plan, hygiene, nutrition, social activities, mobility, pressure sore risk assessment, dependency, moving and handling and daily record. There was evidence to show that wherever possible residents have been involved in identifying their care. This being shown by their signatures. Care plans also showed evidence of promoting resident’s independence, respect, dignity and choice. This was also confirmed by residents and observed during the inspection. Staff were seen to speak to residents in a calm and polite manner and handle many of the frail residents in a gentle manner. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 11 Registered nurses are responsible for the administration of medication. The manager has also carried out 2 internal audits of medication to monitor the quality. Comments from residents were, “the staff are very kind”, “excellent care”, “I always find the staff very kind and helpful”. Comment cards from 12 residents also echoed these views. Comments were, “I believe the whole care is very good” and “I find the staff diligent, caring and supportive at all times”. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Social activities are well managed with the involvement of residents. Residents receive good and nourishing meals. . However a number of residents feel that the activities and food provided could be improved. Visitors can visit whenever they wish to do so. EVIDENCE: The home has no written activities programme but on admission to the home details of resident’s interests are obtained. The home has established regular resident’s meetings, which at their request takes place every two months. Activities include bingo (Monday), exercise class (Wednesday) and visits by outside entertainers. The league of friends from Holbeach Hospital provides these activities with the involvement of care staff. Residents were offered a choice of well-balanced and wholesome meals and a number commented positively on their enjoyment of the food provided. Comment cards however showed that a number of people did not like the Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 13 range of activities and meals provided. This issue was discussed with residents during the inspection and the acting manager. Comments were, “the food is excellent”, “they need to do something about the food and the way it is cooked”, “the food is very good and wholesome” and “I can tolerate the food they provide but it does not suit my cultural background”. Visitors commented they could visit whenever they wished and always made to feel welcome. , Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home takes the issue of addressing complaints and ensuring that residents are safe very seriously and has a comprehensive complaints and adult protection procedure EVIDENCE: Each resident receives a detailed complaints procedure when they are admitted to the home. One complaint had been received by the CSCI and the home since the last inspection. Records showed the manager was addressing the issue and had kept CSCI informed of the progress. None of the residents had any complaints about the home and felt they could discuss any concerns with staff or the manager. Staff also knew what to do if they received a complaint from a resident. As part of the homes’ induction programme all staff receive training concerning abuse prevention and all staff receive checks by the Criminal Records Bureau. This was confirmed by the examination of 2 staff records. Staff also showed knowledge of what constituted abuse and what they should do if abuse was suspected. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home is well maintained, clean and attractively decorated. Furnishings are of a high standard and any maintenance required is attended to swiftly. Residents are also safe. EVIDENCE: Residents who spoke to the inspector said how satisfied they were with decoration and cleanliness of the home. They all spoke of how they liked their bedrooms. There are also attractive, colourful, accessible garden and patio areas. There are a large number of hoists and pressure relieving equipment provided to ensure that residents are cared and managed safely. Staff have received training and knew how to use the equipment safely. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 16 The home employs separate staff for domestic and laundry services. Gloves and aprons are provided and the home has infection control policies. There is a large laundry in the grounds of the home. There are sluice cycles on both of the commercial washing machines. There are also commercial tumble dryers. There is also an enclosed sluice on both ground and first floors All the 12 comment cards showed satisfaction with the cleanliness of the home. Comments from residents were “I have just had my room redecorated and the home is always clean”. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. There is a well trained and competent staff team. The numbers of staff are sufficient for the numbers of residents. Staff are correctly recruited and there is a very well established team. EVIDENCE: The home has exceeded the level of 50 of staff that should have obtained care qualifications by 2005. There are now 80 of staff who have a qualification in care. All staff receive an appraisal annually. In addition to this training the home has provided an extensive in house training programme. There is an extensive training programme for staff, which includes training in care, internal lectures and training from outside trainers. Staff said how the training provided had enabled them to improve the care and support for the residents. There are also nurses who have responsibility for palliative care, tissue viability and continence. Care staff do not receive a copy of the General Social Care Council’s Codes of Practice which sets out their responsibilities as care workers caring for and supporting vulnerable adults. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 18 Residents did not express any worries about the level or availability of staff. Comments were, “magnificent” and “the staff do all they can to help me”. During the inspection staff were seen to promptly attend to residents needs. Comment cards stated, “I am always able to have a member of staff available, at hand without delay” and “my wife recently was poorly, she had immediate attention from a local GP and following that was most carefully nursed”. Staff also felt they had sufficient time to care and support the residents. Comments were “I have been here for many years and love it”, “we work well together”, “I enjoy what I do” and “I felt supported during my induction”. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home is without a registered manager. However there was no evidence to show that the home was not well managed. There is a confident, supported team of staff working in this home. EVIDENCE: The home is without a registered manager. However a person has been recruited who is a registered nurse, has 16 years experience of working in the home and has wide knowledge in care and support of people. An application is to be sent to CSCI in the future in order for this person to be registered by the Commission. This person has also achieved a management qualification. The home had detailed policies and procedures, which included employment, induction and training. This enables staff to care and support residents. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 20 Staff receive formal supervision six times a year. New staff also receive a comprehensive structured induction programme. Comments from staff were “we work together”, “the manager is very supportive and approachable”, “I feel valued”, “and I have received a lot of support and training”. Monies kept on behalf of residents were well maintained with receipts. They were also audited regularly and kept securely. Policies and procedures were reviewed in June 2004. In addition, there were clinical procedures. As part of its quality assurance system a resident satisfaction survey was sent out in August 2005. Thirty one questionnaires were sent out and 18 returned. Comments in the main were very positive. The home also has a staff quality circle and regular staff and residents meetings. The home also receives monthly unannounced visits by members of the trust. Copies of these reports are sent to the CSCI. The manager has also introduced internal audits to monitor the quality of services provided by the home. Comments from residents were, “excellent”, “I have no concerns”, “staff are very kind” and “superb staff”. The home has a detailed health and safety polices which include COSHH (Control of Substances Hazardous to Health), Legionella and risk assessments where required. The home also has a health and safety committee, which monitors this issue. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 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 3 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 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 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 22 no 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. Standard Regulation Requirement Timescale for action 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 OP29 OP33 Good Practice Recommendations It is recommended that each member of the care staff is given a copy of the General Social Care Council’s Codes of Practice It is recommended that the acting manager carry out a survey of residents to obtain their views about the variety and type of activities and food provided by the home. This should also include the dietary needs of people from other races and cultures. Holbeach Hospital DS0000002592.V288157.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 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.V288157.R01.S.doc Version 5.1 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. 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. 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