Inspection on 07/11/05 for Holbeach Hospital

This inspection was carried out on 7th November 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 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 Unannounced Inspection 7th November 2005 08:30 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.V263104.R01.S.doc Version 5.0 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.V263104.R01.S.doc Version 5.0 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.V263104.R01.S.doc Version 5.0 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. Date of last inspection 4th May 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. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 Page 5 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 33 occupied beds in the care home and 6 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 DS0000002592.V263104.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and started at 8.30 am. It took place over 5 hours. The inspector spoke to 7 residents, two visitors, 6 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 2 comment cards were also received. They were both very complimentary. What the service does well: What has improved since the last inspection? What they could do better: The acting manager needs to extend the internal audits to include care records and care practice. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 Page 7 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.V263104.R01.S.doc Version 5.0 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.V263104.R01.S.doc Version 5.0 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, 4, 5 and 6 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: All residents are assessed before entering the home and written confirmation is sent to them that the home is able to meet their needs. There is a detailed statement of purpose and service user’s guide. Both of these documents had been reviewed since the last inspection. 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. Staff receive a comprehensive induction programme, which enables them to understand the needs of the residents in the home. One recently appointed new member of staff commented, “I received a well planned induction and had a member of staff who supported and guided me during my induction”. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 Page 10 Residents can have a trial visit lasting up to 8 weeks to see whether or not they like the home. Comments from a resident were, “I have come here for rehabilitation care and received a very warm welcome and found staff very kind and helpful”. The home does not provide intermediate care. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 11 There is good care planning in this home, which has improved. The health and welfare needs of the people living in his home are fully met. Resident’s dignity is also met. Staff know how to support residents and their families at time of death. The recording of medication has improved. 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. Registered nurses are responsible for the administration of medication. Examination of a sample of medication records showed that records had Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 Page 12 improved since the last inspection. The home has also carried out 2 internal audits of medication to monitor the quality. Staff receive training on how to care and support those residents who are dying and to their relatives. The home also has a detailed policy concerning death and bereavement, which gives guidance to staff. A visitor commented, “my mother could not have received kinder care from any other place. My family received a lot of sensitive, kind support from the staff here”. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Social activities are well managed with the involvement of residents. Residents receive good and nourishing meals. 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. The last meeting was in October 2005. 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 commented positively on their enjoyment of the food provided. As a result of the recent resident’s meeting a hot choice has now been included at the evening meal. Comments were, “the food is very enjoyable and well cooked”. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 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 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. No complaints have been received by the CSCI and home since the last inspection. 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. All staff receive adult protection training and staff knew what to do if adult abuse was suspected. An allegation of abuse was received in September 2005 and was investigated by Lincolnshire County Council’s Social Services Department and the CSCI. This investigation was completed in September 2005. Holbeach Hospital fully co-operated throughout this investigation. There was no evidence to support the allegation. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 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, 21, 24, 25 and 26 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: On the ground floor there are 2 bathrooms (one being on the Anne Waltham GP unit). On the first floor there are 4 bathrooms. All bathrooms in the home have toilets with disabled access. In addition, there are 7 toilets on the ground floor and 1 on the first floor. There are also staff and visitor’s toilets. All toilets and bathrooms have locks, which can be accessed by staff in case of an emergency. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 Page 16 There are 11 single bedrooms on the ground and 21 on the first floor. There are 2 double on the ground and 5 on the first floor. A total of 32 single and 14 beds in double bedrooms. Bedroom sizes range from 10.08 to 21.47 square metres. Thermostatic controls have been installed to all baths and washbasins throughout the home. Temperatures were monitored by the home and records examined on the day of the inspection showed the hot water temperatures were within safe limits. Low surface temperature radiators have been installed throughout the home to enable a guaranteed surface temperature of 43º Centigrade. Legionella checks had been carried out and showerheads were cleaned regularly 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 Residents commented on the cleanliness of the home. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 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 and 30 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 required to have obtained care qualifications by 2005. 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 and continence. Residents did not express any worries about the level or availability of staff. Comments were, “staff are very kind and sensitive and there when I need them”. During the inspection staff were seen to promptly attend to residents needs. Staff also felt they had sufficient time to care and support the residents. Comments were “I received an induction which helped me understand the needs of the residents” and “I feel safe working here”. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 34, 35, 36, 37 and 38 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. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 Page 19 The home had detailed policies and procedures, which include employment, induction and training. This enables staff to care and support residents. Staff receive formal supervision six times a year. New staff also receive a comprehensive structured induction programme. Comments from staff were “we work as a team” and “when I go home I know I have done a good job”. Records examined on the day of the inspection were well maintained, up to date 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, which last met in August 2005. The home also receives monthly unannounced visits by members of the trust. Copies of these reports are sent to the CSCI. 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.V263104.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x x 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 3 x x 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x 3 3 3 3 3 Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard OP33 Good Practice Recommendations It is recommended that further action is carried out to introduce audits of care practice, care records and the environment. Where concerns arise as a result of these audits an action plan should be prepared to address any shortcomings. Holbeach Hospital DS0000002592.V263104.R01.S.doc Version 5.0 Page 22 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. 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