Holbeach and East Elloe Hospital Trust

Updated 16 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak.

Inspection team

The inspection team was made up of 2 inspectors and an expert by experience who carried out telephone calls following our visit. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Holbeach and East Elloe Hospital Trust ia a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Holbeach and East Elloe Hospital Trust is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post, however they were not present for the inspection process and shortly after our inspection left the service.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the nominated individual for the trust registered to operate the care home, the deputy manager; 1 nurse, 3 care staff, 1 housekeeper and the cook. We also spoke with 6 people and 1 relative about their experience of the care provided. We undertook telephone calls to 19 relatives after our visit.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of written records including 8 people’s care files, 4 staff recruitment files and information relating to the auditing and monitoring of service provision.

After the inspection

We reviewed further information we had requested from the provider.

Updated 16 May 2023

About the service

Holbeach and East Elloe Hospital Trust is a nursing home providing personal and nursing care to 43 people aged 65 and over at the time of the inspection. The service can support up to 47 people. Holbeach and East Elloe Hospital Trust provides beds for residential care, local GP’s and reablement beds.

People’s experience of using this service and what we found

The risks to people’s safety were not always well managed and lessons were not always learned to reduce risks to people’s safety. People’s personal emergency evacuation profiles (PEEPs) lacked clear individualised information to support people in an evacuation. The provider addressed this following our visit.

The service was at times short of staff, however the provider was working to improve recruitment of new staff. Staff were not always provided with supervision to support them in their roles.

Quality monitoring processes were not always used effectively to monitor the care people received. There was a lack of ways for people and relatives to feedback their opinions of the service to the provider.

More positively, people’s medicines were well managed, and the service was clean with staff showing good knowledge of infection prevention and control practices. People’s care plans contained good information to support their care and nationally recognised assessment tools were used to assess people’s needs.

People lived in a well-maintained environment and the provider continued to work to improve the building for the people who lived there.

People’s nutritional and health needs were well managed. Staff worked with external health professionals effectively to achieve good outcomes for people. Staff received appropriate training for their roles.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff supporting people were kind and caring and treated people with respect. People were supported to see their family and friends and take part in social activities at the service.

People and relatives felt able to raise any concerns to the staff team and were confident issues would be dealt with. People were protected from the risk of abuse as the provider had systems and processes in place to manage any safeguarding concerns.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement. (published 12 November 2021). This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We inspected this service as part of our inspection programme.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

Since our inspection the provider has worked to address the concerns we found at our inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Holbeach and East Elloe Hospital Trust on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.