Inspection on 04/05/05 for Holbeach Hospital

This inspection was carried out on 4th May 2005.

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 31/05/06

Holbeach Hospital 07/11/05

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 Toby Payne Unannounced 4 May 2005 8.45 hours The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holbeach Hospital Address Boston Road Holbeach Spalding Lincs PE12 8AQ 01406 422283 01406 425752 manager@holbeach-hospital.org.uk Holbeach & East Elloe Hospital Trust Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Jean Garner CRH Care Home with nursing 46 Category(ies) of OP 44 registration, with number of places Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Registered number also include 9 beds in the Anne Waltham Unit 1 Physical Disability named person 56 years and over (Holbeach Hospital), 1 Physical Disability named person 45 years and over (Ann Waltham Unit). Date of last inspection 25th January 2005 Brief Description of the Service: Holbeach Hospital is a care home providing nursing care only. The home is a converted hospital and is managed by the Holbeach and East Elloe Hospital Trust. The trust celebrated its 15 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 29 occupied beds in the care home and 5 in the GP unit. The home is a two-storey 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. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 8.45 a.m. It took place over 5 and a half hours. The inspector spoke to 10 residents, 6 staff, a visitor as well as the manager. The main method of inspection was called “case tracking”. This involved selecting three residents and tracking the care they received through the checking of records, discussion with them, the care staff and observation of care records. Comment cards had been received prior to the inspection from 2 visitors. What the service does well: What has improved since the last inspection? A smoking room has been provided for staff and staff have been made more aware of fire prevention. This has increased the safety of residents. A programme of redecoration has taken place with new curtains and different colour schemes. Two special pressure relieving mattresses have been bought, which has improved the care for residents who are at risk of developing pressure sores. Activities have been reviewed following discussion with residents. These now includes gentle exercises and visits by pets and outside entertainers. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 6 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 C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 3 Holbeach Hospital meets the needs of residents coming into the home. People receive an assessment, which results in their assessed needs being met. EVIDENCE: There is a comprehensive admission procedure, which identifies the needs of residents coming into the home. There is also a detailed, up to date large print service user’s guide and statement of purpose. A copy of the service user’s guide is given to each resident when moving into the home. Each resident is also given a detailed contract/terms and conditions when moving into the home. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9 and 10 There is a clear and detailed care planning system in this home. This ensures that the health and welfare needs of people living in the home are fully met. Medication administration records need to be improved as this could place residents at risk. EVIDENCE: All residents had detailed and up to date care plans. These described their health and welfare needs. Records outlined 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 C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 10 Registered nurses are responsible for the administration of medication. Examination of a sample of medication records showed that 9 had either incomplete entries, gaps or confusing instructions. This could cause errors to be made. The home is required to address this issue. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 Social activities have improved and are well organised. This has provided a stimulation and interest for people living in this home. Meals provided are nutritious, balanced and offer a healthy and varied diet. Visitors are made to feel welcome and supported. EVIDENCE: Residents said they enjoyed the food. Comments were, “the food is very good”. Although there is a set menu, an alternative can be made available. There are regular resident meetings, which take place 4 times a year (a notice was displayed on a notice board giving details of a meeting on the 11/5/2005). A recent survey had resulted in additional social activities. This includes gentle chair exercises, visits by outside entertainers and pets. Activities are provided by the league of friends of Holbeach Hospital with the involvement of care staff. A visitor commented, “I could visit whenever I wished and was always made to feel welcome whenever I visited the home”. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Any complaints received are handled properly and residents know that any complaints they have will be listened to and taken seriously. EVIDENCE: Each resident receives a detailed complaints procedure, which is in large print when they are admitted to the home. In addition, the complaints procedure is also displayed in a large easy to read poster in the reception area of the home. No complaints have been received by the CSCI since the last inspection. The home received one complaint but records examined showed that the complaint had been addressed to the satisfaction of the complainant. None of the residents had any complaints about the home and felt they could discuss any concerns with the staff or the manager. Staff also knew what to do if they received a complaint from a resident. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 23 and 26 Residents live in clean, well decorated, safe accommodation. 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. There are domestic and laundry staff and residents commented that laundry could be returned on the same day. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 There was a well trained and competent staff team. The numbers of staff were sufficient to meet the needs of the residents. Staff were correctly recruited. EVIDENCE: Examination of a staff file of a member of staff who had been recently recruited showed that they had been correctly recruited. None of the residents expressed any worries about the level or availability of staff. During the inspection staff were seen to attend to residents promptly. One resident commented, “staff are always there whenever I need any help”. Staff also felt they had sufficient time to care and support the residents. One member of staff commented, “there is a more flexible routine which has helped us address the needs of the residents”. There is an extensive training programme for staff, which includes National Vocational Qualifications, internal lectures and training from outside trainers. Staff told the inspector how the training had enabled them to improve the care and support to the residents. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 and 33 The home is well lead by a competent, experienced and committed manager who has been in post since July 2002. This has lead to a confident, supported and trained staff team. People living in the home are confident in the staff and management of the home and are consulted about changes. EVIDENCE: The manager has extensive care and management experience obtained both nationally and internationally. She is a registered nurse and has obtained a Batchelor in Sciences in Health Services Management. A visitor commented that “I received a lot of support from the manager and staff whenever I visited the home and this lead me to have confidence in the way staff cared for my relative”, “ I was kept fully informed and the staff thought of me and my relative at all times. My relative could not have received better care”. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 16 There are regular staff and resident meetings. All staff have completed appraisals and formal staff supervision is to be introduced for care staff in the future. Residents and staff felt they could approach the manager if they had any concerns. The Holbeach Hospital Trust carries out monthly unannounced monitoring visits and copies are sent the CSCI as well as the chairman of the trust. Management systems are in place and quality assurance and audit systems are being introduced. These systems however need more development especially concerning medication administration. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 3 x x x 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 Standard No 16 17 18 Score 3 x x 3 3 3 x x x x x Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 18 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. 1. Standard 9 Regulation 13(2) Requirement Staff responsible for the adminstration of medication must follow the procedure for the adminstration of medication. All staff must indicate by their initials that medication has been adminstered in accordance with the instructions on the medication adminstration record. Medication names and instructions must be written clearly so that all responsible know what to do. The manager must ensure that staff are competent to administer medication and made aware of their responsiblities in accordance with the Nursing Midwifery Council Guidelines for the Administration of Medicines January 2004. Audits must also be introduced in order to ensure that staff are following the procedures. Timescale for action 5-6-2005 Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 19 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 33 Good Practice Recommendations It is recommended that further action is carried out to introduce audits of care practice, records, medication and the environment. Where concerns arise as a result of these audits an action plan should be prepared to address any shortcomings. Holbeach Hospital C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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 C53 C04 2592 Holbeach Hospital 224200 040505 Stage 4.doc Version 1.30 Page 21 - 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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