NATIONAL ASSEMBLY FOR WALES

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1 NATIONAL ASSEMBLY FOR WALES HEALTHCARE INSPECTORATE WALES Care Standards Act 2000 INSPECTION REPORT Private and Voluntary Healthcare Marie Curie Centre Holme Towers Penarth Date of Inspection 20 th October 2006 You may reproduce this Report in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of the National Assembly for Wales.

2 Regulation Team Healthcare Inspectorate Wales Bevan House Caerphilly Business Park Van Road, Caerphilly, CF83 3ED INSPECTION REPORT Inspection Episode: April 2006 to March 2007 Healthcare Provision: Marie Curie Centre Holme Tower Contact telephone number: Registered Provider: Marie Curie Cancer Care Responsible Individual: S Munroe Registered Manager: Vivienne Cooper Number of places: 30 Category: Specialist Palliative Care Hospice Date of first registration: 25 July 1986 Date of publication of this report: 19 th February 2007 Date of previous published report: 5 th December 2005 Lead Inspector: P Price Specialist Inspectors/Advisors: H Davies Dr J Hales M Warsop H Nethercott PP/SF-Marie Curie

3 GUIDELINES ON INSPECTION INTRODUCTION This report has been compiled following an inspection of the home undertaken by the Healthcare Inspectorate for Wales (HIW) under the provisions of the Care Standards Act 2000 and associated Regulations. The primary focus of the report is to comment on the quality of life and quality of care experienced by patients. The report contains information on the process of inspection and records its outcomes. The report is divided into nine distinct parts reflecting the broad areas of the National Minimum Standards. An overall conclusion of the home s compliance with Private and Voluntary Healthcare (Wales) Regulations 2002 is recorded. The HIW s Inspectors are authorised to enter and inspect healthcare establishments at any time. At each inspection episode or period there are visit/s to the service in addition to a range of other activities, self- assessment and the use of questionnaires. HIW try to find the best way of capturing patients, their relative/representatives and staff employed within the service experiences. At any other time throughout the year visits may also be made to the service to investigate complaints and in response to changes in the home. Inspection enables the HIW to satisfy itself that continued registration is justified. It ensures compliance with: Care Standards Act 2000 and associated Regulations whilst taking into account the National Minimum Standards The setting s own statement of purpose Readers must be aware that the report is intended to reflect the findings of the inspector at the particular inspection episode. Readers should not conclude that the circumstances of the service will be the same at all times; sometimes services improve and conversely sometimes they deteriorate. The National Minimum Standards are also very detailed and some are technical in nature and the HIW does not look in depth at all aspects of these standards on each visit. The report clearly indicates the requirements that have been made by HIW. This includes those made by HIW since the last inspection report which have now been met, requirements which remain outstanding and any new requirements from this recent inspection. The reader should note that requirements made in last year s report which are not listed as outstanding have been appropriately complied with. If you have concerns about anything arising from the Inspector's findings, you may wish to discuss these with the HIW or with the registered person. The Healthcare Inspectorate Wales is required to make reports on registered facilities available to the public. The report is a public document and will be available on the National Assembly web site: PP/SF-Marie Curie

4 OVERALL VIEW OF THE HEALTHCARE SETTING A Hospice providing palliative care for adults owned and operated by Marie Curie Cancer Care and managed by Vivienne Cooper. It is situated in a residential part of Penarth. Management of the hospice is of a democratic and open style with clear auditing procedures in place that assess the care and provision both within the hospice and against other Marie Curie establishments. The atmosphere is very positive and it is clear that staff are encouraged to develop care and enjoy working there. The care clearly meets the National Minimum Standards and there are aims to ensure continual improvement of care. The treatment provided is person centred and needs assessments are thorough and based on recognised evidence. Palliative care provision is based on All Wales s standards that staff are aware of and the standards are constantly monitored and audited. Care pathways are in place for a number of different patient problems. Procedures and policies are available to, and used by, staff to guide in care provision. The views of the patients regarding all aspects of the care provision are gained through surveys, audits and formal interviews. The results are fed back into the service. The registered manager is an experienced registered nurse with a wealth of experience in palliative care and management. General management of the establishment is satisfactory and staffing, recruitment and retention procedures are appropriate and effective. The registered nurses and the other professionals working at Holme Tower have the appropriate skills and experience to provide quality care. The manager and staff must be commended on the high standards within the hospice. The patients, manager and staff at Holme Tower are thanked for their co-operation and assistance during the inspection. METHODOLOGIES USED IN THIS INSPECTION A planned review took place over one day and consisted of five reviewers. One of these had specialist expertise in the field of palliative care, the reviewers talked to the manager about the previous review findings and areas that were of previous concern. they were then shown around the hospice and talked to both patients and staff to obtain views about the care and running of the hospice. they reviewed the documentation, computer systems, wards, kitchens and associated maintenance as well as the general décor and furnishings of the establishment. all areas were reviewed in relation to the national minimum care standards for private and voluntary health care and standards for hospice care. other benchmarks for the review were professional and legal requirements agreed at a national level. PP/SF-Marie Curie

5 INFORMATION PROVISION Inspector s findings: Holme Tower has a clear statement of purpose and service user guide containing easily accessible information. It is noted and commended as good practice the question and answer booklet which forms part of the information available to patients and relatives/carers. Requirements made since the last inspection report which have been met: When Completed Requirements which remain outstanding from previous inspection activity: To have been completed by New requirements from this inspection: Timescale for completion Good practice Recommendations: PP/SF-Marie Curie

6 QUALITY OF TREAMENT AND CARE Inspector s findings: It is clear that care is person centred, based on evidence and of a high standard. There are clear monitoring and auditing systems on place. Patients and staff can and do feed back about care. There are appropriate police and procedures in place to assist staff with the provision of care. The palliative care handbook (All Wales Minimum Standards) is provided to all staff on commencement of their employment. This document is used to set the standard for the care provided. A clinical governance framework is also in place to ensure that care is based on current research-based best practice. This incorporates National Standards for Palliative Care. This underpins the speciality and incorporates the National Institute for Clinical Excellence guidance. The service is audited annually and the results sent to the Cancer Services. The centre utilises care of the dying Care Pathways. Assessment documentation is in place for each professional discipline providing care. The establishment has a number of audit mechanisms both external and internal that fully examine all aspects of the care provision including the environment. The information from these audits is fed into the ongoing development plan and annual report. The clinical governance framework also ensures that quality is maintained. Opportunities for feedback are given to patients and carers, and complaint information is also fed into the review process that is ongoing. To ensure that dying and death are handled appropriately and sensitively, Care Pathways are used. All staff that do not have palliative care qualifications on commencement of their employment complete the Principles of Palliative Care course. Nurses working at the hospice have a variety of qualifications relating to palliative care from Diploma level upward. A number of staff are trained in bereavement counselling, the social worker is the lead person in this area. There are a number of mechanisms by which the views of the patients are gained including the complaint s framework. These include an annual national help the hospice survey. A questionnaire and stamped address envelope is given to all patients, including those attending the day hospital. The results are then feedback to the centre. An external auditor from another Marie Curie centre also undertakes an internal audit of all systems on an annual basis. The research co-ordinator based in the centre is also undertaking random interviews with patients and families with regard to their experience within the centre. The information provided in these reports is then fed into the development programme. The majority of trained nurses have also undertaken the Department of Health Communications Skills course. The establishment has a comprehensive and appropriate set of policies and procedures in place to guide staff in all areas of activity in the home. The Royal Marsden manual is used to guide clinical practice and as well as the policies and procedures that relate to activity across the organisation, specific locally relevant policies and procedures have also been produced. Policies are also reviewed in line with national guidelines, best practice and any change in legislation. Policies are time-dated. The manager states that staff have to sign with regard to reading key policies. A memo is sent to the ward sisters who would lead in ensuring that staff read identified key policies and signed stating that they had done so. PP/SF-Marie Curie

7 Requirements made since the last inspection report which have been met: When Completed Requirements which remain outstanding from previous inspection activity: To have been completed by New requirements from this inspection: Timescale for completion Good practice Recommendations: It is recommended that a loop system be made available to assist patients with hearing difficulties. PP/SF-Marie Curie

8 MANAGEMENT AND PERSONNEL Inspector s findings: Marie Curie Cancer Care is the registered provider of this establishment with an operational manager managing the establishment on a day to day basis. The manager of the hospice is registered and has the skills and experience required to carry out her role. Criminal Records Bureau checks have been satisfactory and she maintains her registration with the NMC. The manager takes opportunities for continuos professional development. The organisation of the management structure is clear and lines of accountability are set out in an easily identifiable manner. The structure is explained to the patients on admission and is set out in the patients guide. The Criminal Records Bureau checks all staff and there are systems in place to ensure that all staff are up to date with their professional qualifications. However, it was noted that some voluntary administrative staff have not undergone a CRB check. This was discussed with the manager and an audit needs to be undertaken to verify if these members of staff have any contact with regard to patient information. There are appropriate personnel policies and procedures in place. There are systems for ongoing education of staff. Those staff who do not have specific palliative care qualifications, as stated previously, are enrolled onto appropriate courses. Ongoing staff professional development is promoted at the centre. There is a system for group clinical supervision and individual supervision is available but this is not taken up by the staff. Agency staff when utilised, are obtained from appropriate agencies. Where possible the same staff are used to ensure continuity of care for patients. All the registered nurses are given encouragement and assistance in maintaining their registration requirements relating to ongoing training and development. Re-registration requirements are held on a computer base, with a flag up system. As stated previously most registered nurses have experience or qualifications in palliative care, and if not they are required to attend appropriate courses. The standards of nursing care are monitored within the quality assurance and clinical governance frameworks and clinical supervision is being developed. Annual staff appraisals are ongoing and staff development plans put in place. All medical practitioners working within the establishment are recruited using appropriate policies and procedures and all appropriate checks on the individual's background both personal and professional are carried out. After employment on going professional practise and development is monitored by the clinical governance committee and registration is checked on a routine basis dependent on the length of time between registration and renewal. All staff are provided with a handbook that clearly identifies their responsibility to work within the requirements of their professional code of conduct or equivalent. Time and or funding is provided to staff to assist them in meeting the requirements for continued registration with regard to ongoing training and development. The clinical governance committee, monitor all aspects of practise to ensure that professional standards are maintained. PP/SF-Marie Curie

9 Medical questionnaires are completed prior to employment and a health reference from the GP is gained. The establishment has an occupational health service, bought in from the local NHS Trust, which undertakes health screening. Policy and procedures in place. Children are not treated at Holme Tower however due to the nature of care provided some bereavement counselling of children is conducted by the social worker who is fully aware of the Children Act. Protection of vulnerable adults procedures are in place. All staff under go Criminal Records Bureau checks. All applicants for employment are checked with references and professional registration checks being required. Confidentiality is maintained appropriately and staff, are fully aware of the need to report any breaches of this and any other poor practice or abuse. Staff appeared to be fully aware of the range of actions that might constitute abuse and were clear on the reporting mechanisms in the establishment. It is noted and commended as good practice the fact that all staff in the centre have received and/or will receive training in the protection of vulnerable adults issues. Requirements made since the last inspection report which have been met: When Completed Requirements which remain outstanding from previous inspection activity: To have been completed by New requirements from this inspection: CRB checks need to be undertaken where required. Timescale for completion Four Months Regulation 18 Good practice Recommendations: Whilst there are currently no problems with staff sickness, stress or burnout and there are clear auditing systems in place via multidisciplinary case meetings that allow staff to review their practice regularly, the place of individual clinical supervision should remain available should staff wish to undertake this. PP/SF-Marie Curie

10 COMPLAINTS MANAGEMENT Inspector s findings: Clear systems in place for complaint s management. No complaints have been made in the last year. The information provided to patients and visitors details the complaint process. Independent advocacy is available for patients, family and carers. A record is kept of all complaints and outcomes. The complaints are collated and analysed by the Assistant Director of Clinical Governance, Marie Curie Cancer Care, 89 Albert Embankment, London,SE1 7TPLearning outcomes are fed back to the service manager, and/or other service managers as appropriate. The establishment is operated in an open and inclusive manner and the expression of suggestions and concerns are welcomed. There are monthly staff meetings at which they can air their views regarding all aspects of the care provision and other matters. The establishment has a whistle-blowing policy and procedures and there are channels available through the social work department for staff to raise concerns. The chaplain at the home is available to provide informal support to staff. Requirements made since the last inspection report which have been met: When Completed Requirements which remain outstanding from previous inspection activity: To have been completed by New requirements from this inspection: Timescale for completion Good practice Recommendations: PP/SF-Marie Curie

11 PREMISES, FACILITES AND EQUIPMENT Inspector s findings: The premises were maintained to an acceptable standard, and it was noted that a policy of paint a warmer picture, had commenced on the ground floor corridors, which had improved and lightened the circulation areas. Improvements had been made to the lighting with the introduction of energy efficient fittings, and artistic contributions had come from local schoolchildren and the hospice/hospital painting loan scheme. The day unit on the lower ground floor level had been improved with new lighting and soft furnishings, and a replacement carpet was awaiting fitting. The relative s rest room on the ground floor had been redecorated, and funding received for replacement furnishings. Services installations certifications were inspected, and all were currently valid. A new plate heat exchanger unit had been installed as an efficient improvement to the supply of hot water within the premises. As a consequence of this, the current cold water storage facilities were being reviewed with a view to reduction of these supplies. Some window restrains were missing or had broken off windows, and these should be replaced without delay. The small laundry room on the lower basement area was very congested, with red infected linen bags resting close to clean towels and bedding. The policy for this area should therefore be reviewed to prevent this occurrence. Clinical waste is now stored external to the premises in dedicated yellow bins, in accordance with current legislation. These bins should be kept locked, with the key that hangs in the exit corridor. Clinically the environment supports good standard of care with up to date equipment available. Menu plans are provided on a four-week rotational basis. The menus provided appeared to be varied and appropriate to the patients needs and there was a clear indication of choice in the main lunchtime and the evening meals. Meals that were observed during the inspection appeared to be well cooked, well presented and appetising Meals can be adjusted to meet the needs of the patients. The head of catering visits each ward area daily to chat to patients, and also hopes to create visual/picture menus to assist patients in their choices. Adequate numbers of cooks and kitchen assistants are employed to manage the kitchen all of whom have basic food hygiene certificates. The housekeeper and nursing assistants all of whom are involved in the serving of meals also have this training award. Nursing and care staff that serve the meals wear protective aprons over their uniforms, gloves were seen to be in use at the announced inspection. To ensure the meals remain at an appropriate temperature before serving, the bain-marie is plugged in to the wall. During the announced inspection the kitchen was examined for general cleanliness and PP/SF-Marie Curie

12 maintenance. The establishment has a preparation and main kitchen area both were found to be clean and well maintained. Cleaning schedules were in place and appeared to have been followed appropriately. Food temperatures and the temperatures of the fridge's and freezers were recorded on a daily basis and indicated that they were within the appropriate range. The kitchen received a very high score on its last inspection by the Environmental Health Office. This resulted in a silver standard award. Deliveries of fresh meat and vegetables were received on alternate days. Dried goods and other stores were delivered weekly. There were adequate and appropriate stocks of food in the store areas. Food was stored appropriately and time-dated where applicable. Requirements made since the last inspection report which have been met: When Completed Requirements which remain outstanding from previous inspection activity: To have been completed by New requirements from this inspection: Timescale for completion Good practice Recommendations: 1. Replace defective window restraint s. 2. Review laundry policy for storage arrangements. 3. Ensure clinical waste bins are kept locked. PP/SF-Marie Curie

13 RISK MANAGEMNT Inspector s findings: Detailed health and safety risk assessments are completed. Risk Management policies were examined and were appropriate. All accidents, near misses etc are discussed at quarterly meetings and action taken to address any issues raised. Individual risk assessments of patients as well as general risk assessments of the environment are completed and acted upon. Contracts for the supply of equipment and maintenance are in place and contract monitoring ensures a good standard of service. The establishment has a health and safety committee that meets quarterly and all accidents, incidents, near misses are reported to the group. A nominated individual takes the lead in ensuring that all health and safety issues identified are acted on. Risk management training was being provided to staff. Accident records are maintained appropriately and all accidents requiring referral under the RIDDOR rules are reported to the Health and Safety Executive locally. Clinically there are systems in place to reduce risks to both staff and patients, such as moving and handling policies and education and training in the use of intravenous devices. The policies and procedures with the hospice take into account recognise good practice and health and safety requirements and laws. There is a registered pharmacy on site. However, the following was noted on inspection; The fridge temperatures in both wards appeared a little high; it was recommended that this should be investigated. There were some issues concerning the storage and disposal of controlled drugs. Not all schedule 2 and 3 CDs (i.e. patients own CDs) are kept in an appropriately secure designated CD cupboard. It is recommended that a new CD cupboard should be purchased and installed for this purpose as soon as possible. Currently the destruction of CDs is witnessed by a member of admin staff. The destruction should be witnessed by the Home Manager or her deputy. It is recommended that this process should be adopted immediately. It is now a requirement to keep a standard operating procedure for handling schedule 2&3 CDs. Although the hospice has a procedure, it needs to be updated in light of the new CD and waste medicines regulations. It must be noted that above requirements were implemented within the designated timescales. Infection control policies and procedures are in place and appeared to be appropriate. There are infection control manuals in the ward areas. There are clear guidelines on hand-washing and barrier nursing in place within the clinical areas. Staff, appear to be aware and understand the concepts of infection control. Adequate sluicing was available in the clinical area. PP/SF-Marie Curie

14 Cleanliness of the clinical areas was maintained appropriately, with audits completed regularly to ensure that this is the case. Policies and procedures regarding the decontamination of medical devices such as syringe drivers. CSSD arrangements are contracted for through the local Trust hospital and single use/ disposable equipment is used. It is not considered appropriate for advanced life support to be provided for the patients who are admitted to the hospice. This information is clearly stated in the patient s guide. However the wishes of the patient with regard to resuscitation are recorded within their case files. Requirements made since the last inspection report which have been met: When Completed Requirements which remain outstanding from previous inspection activity: To have been completed by New requirements from this inspection: CD medication to be kept in appropriate secure designated cupboard. Destruction of CDs to be witnessed by appropriate personnel. Appropriate and updated operating procedure for 2&3 CDs to be put in place. Timescale for completion One Week Immediate Two Weeks. Regulation 14(5) Regulation 14(5) Regulation 14(5) Good practice Recommendations: PP/SF-Marie Curie

15 RECORDS AND INFORMATION MANAGEMENT Inspector s findings: Patient s records are clear and up to date and all members of the multidisciplinary team use the same record system. Multi-disciplinary records are maintained at the centre. Patients can access their records and they are aware of this. There are computerised systems for personnel, education and policies that staff are aware of and use. There is a back up system in place. The centre has contracted externally for its archiving system. All records required by legislation are in place and all documentation is maintained securely in line with the principles of the Data Protection Act. Policies and procedures are in place. All data protection and Caldicott guidance is followed and the management of information was observed to be satisfactory. Storage was appropriate. Specific personnel are nominated to ensure that the recommendations of the Caldicott enquiry are implemented and followed in practice. Issues of data protection and confidentiality are discussed with staff during their induction into employment. Requirements made since the last inspection report which have been met: When Completed Requirements which remain outstanding from previous inspection activity: To have been completed by New requirements from this inspection: Timescale for completion Good practice Recommendations: PP/SF-Marie Curie

16 RESEARCH Inspector s findings: The hospice has and clear and appropriate research policy, protocols and guidelines to ensure appropriate conduct and research is undertaken with the patient s consent. There is research co-ordinator who supervises all research and some research is undertaken within the hospice. Requirements made since the last inspection report which have been met: When Completed Requirements which remain outstanding from previous inspection activity: To have been completed by New requirements from this inspection: Timescale for completion Good practice Recommendations: PP/SF-Marie Curie

17 OVERALL VIEW OF THE HEALTHCARE SETTING (Where applicable to National Minimum Standards H1- H15) The information provided to patients is clear and easily accessible. Discussion with patients revealed that they were fully involved in decision making about their care. There is ongoing education and training for staff and clinical governance arrangements in place. Assessment is undertaken using a clear assessment tool and directed by the referring Consultant or General Practitioner. There are care plans in place based on evidence and clear ongoing review of the patients condition seen through the documentation. The hospice follows evidence based practice and staff are appropriately educated to deliver this. Patient are involved in deciding their care, care pathways are used, evidence based practice is undertaken and all care is documented daily. There are appropriate policies and procedures in place to reduce infection. There is adequate equipment and education for staff. There is an infection control link person and links to the NHS infection control teams. The aim of the hospice is to provide care for the dying but there is a policy available for resuscitation, staff are trained in the area, there is equipment and patients are consulted with regard to their wishes in the matter of resuscitation. There are trained nursing staff who undertake the administration of medicines. Standard H8 to H10 are fully met, with the exception of standard H 9.5. This standard is partially met see previous comments under Core Standards Risk Management. Standard H11 is not applicable. There are policies and systems in place for the self-administration of medicines but for the most part patients are too ill, frail or unwilling to self-administer their medication. Medical gases are stored and supplied appropriately. The hospice cares for adults only but visiting children are welcomed into a safe environment of care. Inspector s Name : Ms P Price Date: 19 th February 2007 Inspector s Signature: PP/SF-Marie Curie