HEALTHCARE INSPECTORATE WALES Care Standards Act 2000 INSPECTION REPORT Private and Voluntary Healthcare Marie Curie Centre Holme Towers Bridgeman Road Penarth CF64 2AW Date of Inspection 21 st November 2007 & 19 th March 2008 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 Welsh Assembly Government.
Healthcare Inspectorate Wales Bevan House Caerphilly Business Park Van Road, Caerphilly, CF83 3ED INSPECTION REPORT Inspection Episode: April 2007 to March 2008 Healthcare Provision: Marie Curie Centre Holme Towers Contact telephone number: 02920426000 Registered Provider: Responsible Individual: Registered Manager: Marie Curie Cancer Care S Munroe Ms N Rabjohn Number of places: 30 Category: Specialist Palliative Care Hospice Date of first registration: 25 July 1986 Date of publication of this report: 6 th August 2008 Date of previous published report: 19 th February 2007 Lead Inspector: Specialist Inspectors/Advisors: P Price Dr H Davies Palliative Care Specialist Reviewer Marie Curie Holme Towers/0708/FINAL 2
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 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 HIW web site: http://www.hiw.org.uk/ Marie Curie Holme Towers/0708/FINAL 3
OVERALL VIEW OF THE HEALTHCARE SETTING A hospice providing respite and palliative care for adults who suffer from life limiting conditions. It stands in its own grounds and is situated in a residential part of Penarth. It provides inpatient, outpatient and day care. Management of the hospice is of a democratic with clear management structures and auditing procedures in place that assess the care and provision both within the hospice and against other respite and palliative care establishments. The atmosphere is very positive and it is clear that staff are encouraged to develop care and enjoy working there. The care largely meets the National Minimum Standards and there are aims to ensure continual improvement of care. The treatment provided is person centered and needs assessments are thorough and based on recognized evidence. Palliative care provision is based on All Wales standards that staff are aware of and the standards are constantly monitored and audited. Procedures and policies are available to, and used by, staff to guide in care provision. The manager and staff must be commended on the high standards within the hospice. The patients, manager and staff at Marie Curie centre are thanked for their co-operation, time and assistance during the inspections. Marie Curie Holme Towers/0708/FINAL 4
METHODOLOGIES USED IN THIS INSPECTION An announced and unannounced visit took place over two days and consisted of two inspectors, on separate occasions. The Inspector s talked to the manager about the previous review findings and areas that were of previous concern. The Inspector s was then shown around the hospice and had the opportunity to talked to both patients and staff to obtain views about the care and running of the hospice. The Inspector s then 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. Marie Curie Holme Towers/0708/FINAL 5
INFORMATION PROVISION Inspector s findings: Statement of Purpose & Patients Guide Marie Curie Centre has a clear statement of purpose and patient 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. Additional Information A comprehensive range of leaflets is available to assist, guide and inform patients, relatives, carers and any other persons. Patient Satisfaction Questionnaires 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. Advertising The hospice does not advertise its medical services in the media. 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: Marie Curie Holme Towers/0708/FINAL 6
QUALITY OF TREAMENT AND CARE Inspector s findings: Patient-Centred Care 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 feedback 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. Assessment of patients and carers needs. 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. Arrangements for Care The information provided to patients is clear and easily accessible. Patients are fully involved in decision making about their care. Palliative Care Expertise and Training for Multi-professional teams 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 is ongoing education and training for staff and clinical governance arrangements in place. Delivery of Palliative Care The hospice follows evidence based practice and staff are appropriately educated to deliver this. 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. Records of Care Patient are involved in deciding their care, care pathways are used, evidence based practice is undertaken and all care is documented daily. However, it was noted that some entries in patient documentation did not have the actual time, next to entries. Only period of the day i.e. a m. This was discussed with the manager. All ward nurses informed to use appropriate time-date. Regular audits of documentation are undertaken. Quality of Care & Audit 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. Marie Curie Holme Towers/0708/FINAL 7
Care of the Dying The centre utilises care of the dying Care Pathways. Assessment documentation is in place for each professional discipline providing care. Policies & Procedures 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. 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. 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: Ward nurses to record actual time in entries of patients notes. Marie Curie Holme Towers/0708/FINAL 8
MANAGEMENT AND PERSONNEL Inspector s findings: Registered Manager 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 has appropriate qualifications and experience to ensure satisfactory care. Nursing Staff There are appropriate personnel policies and procedures in place. 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. Annual staff appraisals are ongoing and staff development plans put in place. There are systems for ongoing education of staff. There is a system for group clinical supervision and individual supervision is available but this is not taken up by all 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. Human Resources There are appropriate personnel policies and procedures in place. 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. 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. 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. Medical Practitioners 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. Occupational Health 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. Marie Curie Holme Towers/0708/FINAL 9
Protection of Vulnerable Adults 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 mechanism s in the establishment. Children The hospice cares for Adult s only but visiting children are welcomed into a safe environment of care. Children are not treated at Marie Curie centre, 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. Requirements made since the last inspection report which have been met: When Completed CRB checks need to be undertaken where required. Regulation 18 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 noted that a number of staff are declining clinical supervision. In view of the nature of the work it recommended that staff are encouraged to attend regular clinical supervision sessions and that an audit is undertaken to determine why so many staff are declining and whether this can be improved. The organisational chart needs to be updated in light of changes to managers. Marie Curie Holme Towers/0708/FINAL 10
COMPLAINTS MANAGEMENT Inspector s findings: Complaints Management Clear systems in place for complaint s management. 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, 89Albert 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 suggestion s 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. Whistle-blowing 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 hospice 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: Marie Curie Holme Towers/0708/FINAL 11
PREMISES, FACILITES AND EQUIPMENT Inspector s findings: Maintenance Plan There is a rolling programme of maintenance and refurbishment within the hospice. Certificates/Testing Fire risk assessment available. Weekly fire test carried out. Fire extinguishers annual check carried. Emergency lighting checks recorded. Clinical waste is 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. Facilities The environment is clean, bright and welcoming. The hospice is entered via a reception foyer. Patients and visitors can access all areas of the hospice. Clinically the environment supports good standard of care with up to date equipment available. It was noted, that the small laundry room on the lower basement area was very congested and there was an ironing board with iron in the corridor outside. The policy for this area should therefore be reviewed to prevent this occurrence. Catering 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. It was not clear whether nursing staff, who currently serve patient food also have food hygiene training as this question could not be answered by the managers asked and the information was not available in information given to the inspector. To ensure the meals remain at an appropriate temperature before serving, the bain-marie is plugged in to the wall. During the inspection the kitchen was examined for general cleanliness and maintenance. The establishment has a preparation and main kitchen area and 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. 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. Minor work repairs noted during the inspection in November 2007 have been completed. Marie Curie Holme Towers/0708/FINAL 12
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: Fridge/freezer 2 seal requires replacing in the hospice main kitchen. Flooring in the dry goods store in kitchen and adjacent requires repair/resealing. Danger sign with regard to hot water tap to be displayed in main kitchen. Timescale for completion 27 th November 2007 (Completed) 30 th November 2007 Flooring replaced in both areas. (Completed) November 2007 (Completed) Regulation 14(2) (a)&(b) Regulation 24(2) (a) Regulation 24(2)(b) Good practice Recommendations: The policy for the lower basement area should be reviewed to prevent congestion in small laundry room. Marie Curie Holme Towers/0708/FINAL 13
RISK MANAGEMNT Inspector s findings: Risk Management 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. 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. Health & Safety The policies and procedures with the hospice take into account recognise good practice and health and safety requirements and laws. Detailed health and safety risk assessments are completed. 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. Fire Training Fire drills and training in place for staff. However, it was unclear if medical practitioners undertook fire training/drills. Medical practitioners are now included in training schedules at the hospice. Responsibility for pharmaceutical services There is a service level agreement (SLA) with Velindre NHS Trust. A pharmacist is available in the hospice five days a week. Ordering, Storage, use and disposal of medicines. Medicines, dressings and medical gases are handled in a safe and secure manner. Administration of medicines. There are trained nursing staff who undertake the administration of medicines. Self-administration of medicines. 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. Infection Control 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. 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. Cleanliness of the clinical areas was maintained appropriately, with audits completed regularly to ensure that this is the case. It was not clear whether nursing staff, who currently serve patient food also have food hygiene training as this question could not be answered by the managers asked and the information was not available in information given to the inspector. Marie Curie Holme Towers/0708/FINAL 14
Decontamination of Medical Devices Policies and procedures are available 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. Resuscitation 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 Discussion with the manager about resuscitation procedures for the day care area revealed that not all staff working in that area have received training in basic life support. The need for this was discussed. Contracts Contracts for the supply of equipment and maintenance are in place and contract monitoring ensures a good standard of service. Requirements made since the last inspection report which have been met: When Completed CD medication to be kept in October 2006 Regulation 14(5) appropriate secure designated (Completed) cupboard. Destruction of CDs to be witnessed by appropriate personnel. Appropriate and updated operating procedure for 2&3 CDs to be put in place. October 2006 (Completed) October 2006 (Completed) Regulation 14(5) Regulation 14(5) Requirements which remain outstanding from previous inspection activity: To have been completed by New requirements from this inspection: All staff involved with food handling should undergo relevant education and training. Timescale for completion August 2008 Regulation 14(6) and In accordance with The Food Safety Act (1990) All staff who may be required to give basic life support should undergo education and training in this skill. September 2008 Regulation 34(1) Good practice Recommendations: Medical practitioners to be included in fire training/drill schedules at the hospice. Marie Curie Holme Towers/0708/FINAL 15
RECORDS AND INFORMATION MANAGEMENT Inspector s findings: Records Management 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. 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. Storage was appropriate. Specific personnel are nominated to ensure that the recommendations of the Caldicott enquiry are implemented and followed in practice. Health Records 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. Confidentiality 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: Marie Curie Holme Towers/0708/FINAL 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 patients 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: Marie Curie Holme Towers/0708/FINAL 17
ACTION PLAN FROM REPORT Inspector s findings: The focus of the inspection and report for this year has been to report on compliance with the requirements made previously in the context of the compliance with standards and regulations made under the Care Standards Act 2000. Submission of a detailed action plan in relation to the (0) outstanding and (2) new requirements is required as a result of this report as set out below. New requirements from this inspection: When Completed i. HIW requires the submission of an Section 31 (1) Care action plan addressing all the Standards Act 2000 requirements made this year (2) and The registration authority those carried forward (0) in this report. may at any time require a person who carries on or The action plan must clearly identify manages an establishment 1. the requirement, or agency to provide it with 2. the action to be taken, any information relating to 3. person responsible, the establishment or agency 4. due date for completion, which the registration authority considers 5. and a status report as of the day of necessary or expedient to the action plan. have for the purposes of its 6. The plan must be reviewed 3 functions under this Part. monthly, and a copy submitted to HIW on the last day of the third month until all requirements have been met. Inspector s Name: P Price Date: 6 th August 2008 Inspector s Signature: Marie Curie Holme Towers/0708/FINAL 18