Inspection on 24/05/05 for Hatfield Peverel Lodge Residential and Nursing Home

This inspection was carried out on 24th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hatfield Peverel Lodge... 23/10/06

Hatfield Peverel Lodge... 08/03/06

Hatfield Peverel Lodge... 27/02/06

Hatfield Peverel Lodge... 08/11/05

Hatfield Peverel Lodge... 02/02/05

Hatfield Peverel Lodge... 16/11/04

Hatfield Peverel Lodge... 24/08/04

Hatfield Peverel Lodge... 17/08/04

Hatfield Peverel Lodge... 25/11/03

Similar services:

Henrietta House

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Mallard House at Hatfield Peverel Lodge Nursing Home Crabbs Hill Hatfield Peverel Chelmsford Essex CM3 2NZ Lead Inspector Francesca Halliday DRAFT Unannounced th 24 May - 17th June 2005 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. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mallard House at Hatfield Peverel Lodge Address Crabbs Hill Hatfield Peverel Chelmsford Essex CM3 2NZ 01245 380750 01245 380906 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) BUPA Care Homes (CFC Homes) Limited Care Home 71 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (8), of places Physical disability over 65 years of age (41) Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Mallard House Persons of either sex, aged 65 years and over, who require nursing care by reason of dementia (not to exceed 30 persons). Date of last inspection 15 February 2005 Brief Description of the Service: Hatfield Peverel Lodge has two separate houses. Mallard House provides nursing and care for up to 30 people over the age of 65 with dementia. Kingfisher House is registered to provide nursing and care for up to 41 people over the age of 65, although only 40 beds are in use. Both houses are two storey buildings with passenger lifts. The home has 67 single rooms, with two shared rooms on Mallard House. Hatfield Peverel Lodge is located approximately half a mile from the centre of Hatfield Peverel Village and about one mile from local shops and facilities. There is a bus stop within a quarter of a mile of the home and Hatfield Peverel is on the main London to Colchester train route. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 24th May 2005. The inspection lasted 10 hours 15 minutes. The inspection process included: discussions with 10 residents (although advanced dementia made communication difficult with some residents), 4 relatives, and 6 members of staff including the deputy head of care for Mallard House and the manager of the home. Further information was requested at the time of inspection, and this arrived on 25th May. The premises and a sample of records were inspected. Efforts were made to contact two of the health professionals, who regularly visit Mallard House, between 7th and 16th June. A discussion with a GP who visits Mallard House was held on 17th June and this concluded the inspection process. An additional unannounced inspection was carried out in January 2005 to investigate a complaint (see section on complaints for details). 18 of the 38 standards were inspected: none of the standards were fully met, 9 standards had minor shortfalls and 9 standards were not met. The judgements made within the report are based on the observations and evidence gathered during this inspection. The findings were discussed with the manager at the time of inspection, which is why a number of requirements for immediate action can be found in the report. What the service does well: What has improved since the last inspection? The GP spoken with considered that the standard of activities was improving (see below concerning training needs). The overall standard of cleaning had improved, particularly the standard of carpet cleaning (see below concerning cleanliness of chairs and wheelchairs). Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 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. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 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 Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 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 and 3 (standard 6 is not applicable) The information provided by the home enables prospective residents and their representatives to make informed choices about the suitability of the home. The pre-admission assessment process does not consistently ensure that residents are only admitted to Mallard House if the home can meet their needs. EVIDENCE: The home has a range of information for prospective residents and their representatives. The statement of purpose had been updated to reflect the change in manager of the home. The manager was informed of the minor amendments needed to meet requirements. Staff use BASOLL (Behaviour Assessment Scale of Later Life) as a preadmission assessment tool. A sample of pre-admission assessments was seen, and provided evidence of detailed assessments of whether the home could meet the potential residents’ needs. A relative said that they had been happy with the assessment process prior to admission. However, the GP spoken with considered that a poor preadmission assessment process had on some occasions resulted in residents being admitted inappropriately. The manager Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 9 said that she was carrying out assessments with staff to ensure that they were carried out to a consistent standard and in order to identify any potential training needs. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 10 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, 8, 9 and 10 The care documentation does not provide staff with the information they need to satisfactorily meet residents’ needs. Residents’ health needs are not consistently met. Residents could potentially be at risk due to the lack of a functioning suction machine. Care is not always provided in a manner that upholds residents’ privacy and dignity. EVIDENCE: The care plans seen were of a variable standard and in some care records the care and care needs had only been evaluated on a very infrequent basis (in one of the care records sampled the care and care needs had only been evaluated once in twelve months). There was evidence, in a number of care records sampled, that care plans did not cover all care needs and were not updated following changes in condition. In two residents’ records health concerns were noted in the daily progress records, but there was no evidence that staff had taken appropriate actions to address the concerns raised. In one resident’s care documents there was no record of any monitoring of a very frail resident’s pressure areas, until a statement that they had a “deep” pressure sore. There was no evidence of any action taken or any care plan written until eight days later, when the wound was described as having an Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 11 odour and discharging pus. Staff considered that Mallard House had sufficient pressure relieving mattresses but insufficient pressure relieving cushions for residents at high risk of developing sores. Staff spoken with had not received recent training on the prevention and treatment of pressure sores. Fluid and food charts were seen in one resident’s room. However, they were not completed consistently, so would not provide evidence of effective monitoring of the resident’s intake. There was evidence that staff were not always acting as residents’ advocates by obtaining prompt medical advice. The majority of the relatives spoken with said that they had never seen the care plans or been involved in their review, and did not know the name of their key worker or named nurse. One relative said that they had only seen the care plans when they made a specific request, and that staff “had not volunteered”. One relative said that they were very happy with the care provided. Another said “the care is good they are very caring staff”. Two relatives considered that staff managed challenging behaviour well. However, the GP spoken with considered that the management of challenging behaviour could be improved. A number of staff on Mallard House had not received training in dementia care or the management of challenging behaviour. The daily progress records were mainly a record of physical care given. Some monitoring of psychological health was seen, but this was not consistent or detailed enough for analysis. For example, it was not possible to establish whether there were any specific triggers for service users with challenging behaviours from the records seen. The home had a range of risk assessments in place, but a number had not been reviewed on a regular basis (one risk assessment seen had not been reviewed for eleven months). There were some standardised risk assessments in use, which had not been personalised to the individual service user. When a risk was identified there was not always a care plan indicating the actions to take to minimise risk. Three relatives said that staff did not always supervise residents in their room or in the lounge area. Two relatives said residents were left without supervision “occasionally for (a period of) over an hour”. A number of relatives said that specific preferences or care instructions were ignored by staff, to the detriment of residents’ care. In one of the examples given staff were not following the specific positioning needs of a resident. The relative considered that this would have caused the resident considerable pain, which could have resulted in more disturbed behaviour. Staff had made no record of the resident’s positioning needs in the care plans. The Medicine Administration Records (MAR) were generally well completed, but staff had not always documented administration of homely remedies on the MAR. The homely remedy stock levels were checked and the stock balance for one medicine was incorrect. The stock levels for Controlled Drugs were checked and found to be correct. The majority of medicines with a limited life Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 12 had been dated on opening. However, there was evidence that one medicine with a limited shelf life had been in use for ten months. The temperature of the drugs fridge was being regularly monitored. The temperature of the clinical room had not been monitored to ensure that medicines were stored at the correct temperature. Some medicines seen were labelled on the outer carton but not on the medicine container itself. The GP spoken with considered that the ordering of medicines had improved. Mallard House did not have a functioning suction machine for use in an emergency. A discussion was held about the need to ensure that the resident (and/or relative where appropriate), the GP, and the pharmacist are involved in decisions about the covert administration of medicines. A number of relatives gave examples of times that staff had carried out care without upholding residents’ privacy and dignity. Examples included using the hoist in the lounge and not pulling clothes down when underwear was showing. Another example was taking a resident to the toilet without shutting the door, when their relative was in the room. During the inspection one resident was noted to frequently pull their clothes up showing their underwear. Staff did not offer them a cover or pull their clothes down at any time. A discussion was held as to whether the wearing of trousers or slacks might help to preserve this resident’s dignity. A resident who was smartly dressed earlier in the day was noted to have been changed into his pyjamas at 4.30pm. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15 Social activities have improved, but they do not provide sufficient stimulation for residents at all stages of dementia. Relatives are satisfied that residents’ independence is promoted. Visiting arrangements are open and relaxed. Poor communication with relatives impacts directly on residents’ health and welfare. Meals are nutritious, provide a balanced diet and cater for individual dietary needs, but staff do not always ensure that residents’ preferences are met. EVIDENCE: There was evidence of one to one and small group sessions with the majority of residents. However, two relatives were concerned that the activity coordinator did not have enough time to “sit down with residents as she helps out staff with care”. This was discussed with the manager, and the activity coordinator’s role and responsibilities were clarified at the time of inspection. Relatives said that there was no exercise class, which they considered might be beneficial for some residents. Another relative said that they had not noticed any activities with the resident they visited. The activity coordinator had completed a course on seated exercises. She said that she hoped to bring in a regular seated exercise session once she had been fully assessed. The activity coordinator had received some training in activities but not specifically in activities for older people at different stages of dementia. A number of care Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 14 and nursing staff had not received training in the range of activities suitable for older people with dementia. Relatives said that they could visit at any time, said that staff generally chatted to them and made them feel very welcome. However, a number of relatives raised concerns about communication. Two relatives said that staff did not usually tell them if the resident had run out of toiletries. Another was so concerned about poor communication that they were “not reassured that care is as it should be” and added, “I go home and worry”. They said that there had been no relatives meetings and said “feedback is not consistent, staff don’t tell me anything unless I ask”. They said that they frequently had to make numerous requests on behalf of the resident, and that even so requests were frequently ignored. The GP spoken with considered that the communication skills of some staff needed to be improved. Two relatives spoken with considered that staff did try to promote residents’ independence. Residents who could express a view said that they liked the food. Relatives confirmed that food was nutritious the standard was good, and that plenty of choices and different diets were available. However, a number of examples were given whereby residents were not being given the drinks they preferred. In one instance a relative had been supplying the preferred drink, as they were concerned that the resident might become dehydrated if they were always offered drinks that they did not like. The relative considered that all beverages should be supplied by the home. One relative said that a number of staff did not know how to apply denture fixative, and that this had resulted in ill-fitting dentures making it difficult for a resident to eat properly. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 15 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 and 18 Relatives acting on behalf of residents do not feel that concerns raised are consistently acted upon. Insufficient staff have received protection of vulnerable adults training to ensure that the different forms of abuse are recognised, and appropriate action taken if abuse is suspected. EVIDENCE: There was evidence that staff were not documenting concerns and complaints raised with them, and that this was resulting in poor communication and lack of action to address the issues raised. The home manager said that she had not been notified of any of the outstanding concerns or complaints raised during this inspection. A complaint was sent to the Commission and investigated in January 2005. The complaint about lack of hot water on Mallard House for a number of weeks was upheld, the complaints about poor care standards and lack of appropriate activities were upheld in part. Action was taken to address the problems with hot water following the inspection, and additional staff training was provided. The home has policies and procedures in relation to the protection of vulnerable adults (POVA) and whistle blowing. Staff spoken with on the day of inspection had received protection of vulnerable adults training. They were able to demonstrate an awareness of the different types of abuse that can occur, and the actions to take if abuse was suspected. However, according to the training records a number of staff on Mallard House had not received POVA training. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 16 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) 20, 21, 24 and 26 Residents generally live in a clean environment, but chairs and wheelchairs need more regular attention. Residents could potentially be at risk if the temperature in the lounge/dining area becomes excessively hot. The lack of a toilet in close proximity to the lounge/dining area does not encourage residents’ independence and continence. Poor communication with relatives directly impacts on residents’ welfare. EVIDENCE: The home has a large open plan lounge and dining room and two small quiet rooms, one of which was in the process of being set up as a reminiscence room. The manager said that new carpets were due to be laid in the lounge/dining area. Some armchairs in communal areas were very stained. The manager confirmed that new armchairs were on order. A number of relatives said that it sometimes became extremely hot in the lounge/diner area. This has been raised at a previous inspection and staff were asked to monitor the temperature, and take action if the temperature was regularly raised. This has not been done. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 17 Mallard House has twenty-four single and two shared rooms. At the time of inspection one of the shared rooms was being used as a single room. The rooms inspected were generally in good decorative order, although one room seen had considerable paint peeling from some areas on the walls. The manager confirmed that the home had a rolling programme of redecoration. A number of rooms were well personalised with possessions and photographs. However, one relative said that they had made numerous requests to staff over a period of four months for assistance to put up photographs in a resident’s room. These requests had not been acted upon. The relative had put some up themselves, but some others had been damaged while waiting to be put up. The relative was concerned that by the time the photographs were put up the resident’s condition would have deteriorated further, and they would not recognise the people in the photographs. All rooms on Mallard House have en-suite facilities. The home has two bathrooms and two shower rooms. The toilets are clearly labelled with large pictograms. The small lounges have toilets in close proximity. However, the toilet near the lounge/dining area was not accessible to residents. The overall standard of cleaning had improved since the last inspection. Staff agreed that the standard of cleaning had improved and said that a new carpet cleaner had been purchased, and that the frequency of carpet had been increased since the last inspection. Relatives considered that the home was generally kept clean. However, a number of relatives considered that the cleaning of chairs and wheelchairs could be improved, particularly in the dining room. A wheelchair was seen with dried food encrusted on it. They also said that staff did not always clean chairs if a resident had been incontinent. One relative said that there had been a serious problem with the cleanliness and hygiene in a resident’s room on one occasion, and that this had not been addressed until this was brought to the attention of staff. Relatives said that the garden had been in need of attention but that this had now been improved. A number of relatives said that they were very happy with the laundry service. However, one relative felt that residents’ clothes were frequently put in the wrong room. They said that when they had asked about an article that had been lost no action was taken, and staff did not give them any feedback. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 18 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) 30 Some staff do not have sufficient training to enable them to carry out their role safely. EVIDENCE: The home has a comprehensive induction programme for new staff. However, according to the records a number of staff on Mallard House had not received training in the following areas: - dementia care - the management of challenging behaviour - activities for older people at different stages of dementia - the protection of vulnerable adults - moving and handling - fire safety - food hygiene - infection control - health and safety The inspection highlighted the need for staff training on communication and the prevention and treatment of pressure sores. The inspection also highlighted the need for direct staff supervision, monitoring of care practices and identification of individual training needs. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 19 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) 38 Poor moving and handling practices put residents at risk. Staff are at risk of injury due to the lack of moving and handling training. Lack of training for some staff in safe working practices could potentially put residents at risk. EVIDENCE: One member of the domestic staff spoken with had not received any moving and handling training, despite the fact that they had previously hurt their back lifting laundry. Poor moving and handling practice was observed, during which a resident was moved by a member of staff and a relative from an armchair to a wheelchair. The resident was at risk of injury as the wheelchair had no breaks on and an underarm move was used. According to the records seen some staff had not received recent moving and handling training or fire safety training. A number of staff had not received health and safety, food hygiene and infection control training. Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 1 14 2 15 2 COMPLAINTS AND PROTECTION x 1 2 x x 2 x 2 STAFFING Standard No Score 27 x 28 x 29 x 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 2 x x x x x x x 1 Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 21 yes 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 1 Regulation 6 Requirement The registered person must send a copy of the statement of purpose to the Commission when it has been revised. The registered person must ensure that residents are not admitted to Mallard House unless the home can fully meet their needs. The registered person must ensure that care plans cover all assessed needs and identified risks, are updated following changes in residents condition and that care and care needs are evaluated on a regular basis. Requirement in previous reports - timescales of 24.08.04 and 16.11.04 not met. The registered person must ensure that care plans are drawn up and reviewed in consultation with residents and their relatives where appropriate. The registered person must ensure that all nursing and care staff on Mallard House have training on the prevention and treatment of pressure sores. The registered person must ensure that the home has Timescale for action 1.08.05 2. 3 14(1) 24.05.05 3. 7 15(1)(2) 24.05.05 4. 7 15(2) 24.05.05 5. 8, 30 18(1) 1.08.05 6. 8 23(2)(n) 1.08.05 Page 22 Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 7. 8 14(2) 8. 8, 30 18(1) 9. 8 12(1) 10. 8 12(1) 11. 8 14(2) 12. 9 13(2) sufficient pressure relieving cushions for residents at high risk of developing pressure sores. The registered person must ensure that effective monitoring of residents food and fluid intake are put in place, when residents are assessed at very high nutritional risk. The registered person must ensure that all staff receive training in dementia care and the management of challenging behaviour. Requirement in previous reports (dementia care) - timescales of 1.12.04 and 1.04.05 not met. Requirement in previous reports (challenging behaviour) - timescales of 1.12.04 and 1.02.05 not met. The registered person must ensure that residents are regularly supervised in all areas of the home. The registered person must ensure that the daily progress records have details of residents physical and psychological health and how they have spent their day, as well as documenting the physical care given. The registered person must ensure that risk assessment are regularly reviewed and updated following changes in residents condition. The registered person must ensure that the administration of homely remedies is recorded in both the homely remedy book and the medicine administration record, and that a record is made of the multidisciplinary decision making process in relation to the covert administration of medicines. 24.05.05 1.10.05 dementia care. 1.08.05 challenging behaviour 24.05.05 24.05.05 24.05.05 24.05.05 Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 23 13. 9 13(2) 14. 9 13(2) 15. 9 13(2) 16. 9 13(2) 17. 10 12(4)(a) 18. 12, 30 16(2) (m)(n) 19. 13, 24, 26, 30 12(1)(a) The registered person must ensure that medicines with a limited shelf life are dated on opening, and discarded within the recommended timescale. Requirement in previous reports - timescales of 24.08.04 and 16.11.04 not met. The registered person must ensure that the temperature of the clinical room is monitored and action taken if the temperature regularly exceeds 25c, which is the upper safe limit for the storage of medicines. The registered person must ensure that medicines are labelled on the container as well as, or instead of the outer packaging, in order to reduce potential errors if the outer carton is mislaid or the medicine is placed in the incorrect carton. The registered person must ensure that equipment such as suction machines are ready to use in an emergency. Requirement in previous reports - timescales of 26.08.04 and 16.11.05 not met. The registered person must ensure that care is always carried out in a manner which uphold residents privacy and dignity. The registered person must ensure that all staff receive training in the range of activities and stimulation appropriate for older people at different stages of dementia. Requirement in previous report - timescale of 1.03.05 not met. The registered person must ensure that staff receive training on communication, particularly on the importance of good communication with relatives of 24.05.05 24.05.05 1.08.05 24.05.05 25.05.05 1.10.05 1.08.05 Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 24 persons suffering from dementia. 20. 15 16(2)(i) (4) The registered person must ensure that residents preferences are documented and as far as possible met. This refers particularly to ensuring that residents are given the drinks they prefer. The registered person must ensure that all nursing and care staff know how to care for residents dentures and fit them securely. The registered person must ensure that a record is made of all concerns and complaints, including the investigation and management action taken to address the issues raised. This has been a requirement in previous reports - timescales of 24.08.04 and 1.01.05 not met. The registered person must ensure that all staff receive protection of vulnerable adults training. This has been a requirement in previous reports timescales of 1.11.04 and 1.02.05 not met. The regisistered person must ensure that the temperature of the lounge/dining area is monitored, and that action is taken if temperatures are found to be regularly raised. This has been a requirement in previous reports - timescale of 1.12.04 not met. The registered person must ensure that there are toilets in close proximity to all communal rooms, and that they are accessible to residents. This has been a requirement in previous reports - timescales of 1.12.04 and 1.04.05 not met. The registered person must 24.05.05 21. 15 12(1)(a) 24.05.05 22. 16 22 24.05.05 23. 18, 30 13(6) 1.09.05 24. 20 12(1)(a) 24.05.05 25. 21 23(2)(j) 1.09.05 26. 26 23(2)(d) 24.05.05 Page 25 Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 27. 30, 38 13(5) 28. 30, 38 23(4) 29. 30, 38 13(4) 30. 30, 38 16(2)(j) 31. 30, 38 13(3) ensure that armchairs and wheelchairs are checked and cleaned regularly. The person registered must ensure that all staff receive moving and handling training. This has been a requirement in previous reports - timescales of 1.10.04 and 1.01.05 not met. The registered person must ensure that all staff receive fire safety training. This has been a requirement in previous reports timescale of 1.01.05 not met. The registered person must ensure that all staff receive health and safety training. This has been a requirement in previous reports - timescales of 1.01.05 and 1.05.05 not met. The registered person must ensure that all staff receive food hygiene training. This has been a requirement in previous reports - timescales of 1.12.04 and 1.04.05 not met. The registered person must ensure that all staff receive infection control training. This has been a requirement in previous reports - timescales of 1.01.05 and 1.03.05 not met. 1.09.05 1.09.05 1.10.05 1.10.05 1.11.05 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 Good Practice Recommendations Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Mallard House at Hatfield Peverel Lodge Nursing Home I56-I05 S15350 Mallard at Hatfield Peverel Lodge V229312 240505 Stage 4.doc Version 1.30 Page 27 - 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. 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