Inspection on 08/11/05 for Hatfield Peverel Lodge Residential and Nursing Home

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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... 24/05/05

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

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Claremont House

Oak Ridge

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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 Hatfield Peverel Lodge Residential and Nursing Home Crabbs Hill Hatfield Peverel Chelmsford Essex CM3 2NZ Lead Inspector Francesca Halliday Unannounced Inspection Kingfisher House 8th November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hatfield Peverel Lodge Residential and Nursing Home Crabbs Hill Hatfield Peverel Chelmsford Essex CM3 2NZ 01245 380750 01245 380906 Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes (CFC Homes) Limited Ms Pervine King 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) Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The total number of service users accommodated must not exceed 71 persons Mallard House Persons of either sex, aged 65 years and over, who require nursing care by reason of dementia (not to exceed 30 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 2 persons) Kingfisher House Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 41 persons) Persons of either sex, aged 65 years and over, who only fall within the category of old age (not to exceed 8 persons) Date of last inspection 02 February 2005 3. Brief Description of the Service: Hatfield Peverel Lodge has two separate houses. 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. Mallard House provides nursing and care for up to 30 people over the age of 65 with dementia. 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. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was to Kingfisher House only. The inspection took place on 8th November 2005 and lasted 8 hours 40 minutes. The inspection process included discussions with 9 residents, 3 relatives and 5 members of staff including the manager. The premises and a sample of records were inspected. 17 of the 38 standards were inspected: 9 met the standards, 7 standards had minor shortfalls and 1 standard was not met. The judgements made within the report are based on the observations and evidence gathered during this inspection. What the service does well: What has improved since the last inspection? What they could do better: The prevention and management of pressure sores needed to be improved, and training given to all nurses and care staff. The standard of care records was improving, however, the inspection identified a number of areas where more comprehensive documentation was needed. Staffing was not always at previously agreed levels, and discussions will be held too clarify the levels required for different occupancy levels and dependencies. The recording of accidents and equipment maintenance did not always follow procedures. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 6 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. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 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 the following standard(s): Standards 1, 3 and 4. Standard 6 not applicable. Information provided by the home enables prospective residents and their representatives to make informed choices about the suitability of the home. The home generally has a good assessment process prior to admission. However, lack of documentation about personal preferences could potentially result in a mismatch between expectations and what the home can actually offer. EVIDENCE: The home has a range of information for prospective residents and their representatives. Staff used the BASOLL assessment (Behaviour Assessment Scale of Later Life) as a pre-admission assessment tool. A discussion was held about using an additional form as well, to ensure that all the information described in standard 3.3 was also obtained. This particularly refers to ascertaining potential residents’ preferences. The staff on Kingfisher were generally very experienced in care of the older person. Efforts were also being made to provide specific training to meet residents’ specialist needs. A resident said that they were very disturbed by Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 9 one of the residents shouting out both during the day and at night. A relative said that this “had been going on some time”. The manager was asked to confirm that a reassessment was being carried out as to the continued suitability of this resident’s placement. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 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 the following standard(s): Standards 7, 8, 9 and 10. Care plans do not cover all care needs, and are not always sufficiently resident focused. Residents consider that their health and care needs are met, however, improvements are needed in the prevention and management of pressure sores. Medicines management is generally sound. Residents consider that staff uphold their privacy and dignity. EVIDENCE: The home had recently introduced a system of “the resident of the day”, whereby each resident was being reassessed once a month, and their care records updated. A resident confirmed that they had looked at their care records and were happy with their care. Relatives were being invited to attend and discuss the care being provided (when appropriate). Discussions were held about involving residents (and relatives where appropriate) in the initial devising of plans, so that they could be made more resident focused, and also in the evaluation of care and care needs from their point of view. Some good evaluations of care and care needs were seen, but some only contained a review of the care plan. Care plans did not cover all needs identified during discussions with residents and staff. The progress records were mainly a record of physical care given, and had very little information about the Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 11 residents’ mood and psychological health (even when this was particularly relevant) or how they had spent their day. The manager said that training in care planning was due to be given. Two residents had pressure sores. There was evidence that pressures sores had both developed and deteriorated whist the residents were in the home. The records about the pressure sores were in three places and were somewhat confusing. One of the residents with a pressure sore did not have a risk assessment (Waterlow) completed. There was no clear evidence that appropriate action was being taken to prevent pressure sores developing, when high risk was identified, or to heal sores once they had developed. The manager said that staff training in wound care and the prevention and treatment of pressure sores, was due to take place in the near future. Residents had a general health check and were weighed every month. The manager confirmed that she intended to borrow equipment to weigh frail residents who were not able to use the scales. The home had a range of risk assessments, but they were not always reviewed and updated when residents’ condition changed. Some general risk assessments were not personalised to individual residents. Residents confirmed that they were able to see their GP when they had any health concerns. There was evidence that residents were being referred for hospital investigations and treatment where appropriate. Residents said that they saw the chiropodist and had dental and optical checkups. The medicine administration records were well completed. The controlled drugs and homely remedy stock levels were checked and found to be correct. The temperature in the clinical room was being monitored, and there was evidence that staff were taking action when the temperature exceeded 25c. Medicines were being stored appropriately in the drugs fridge. Liquid medicines with a limited shelf life were dated on opening (staff were advised to discard one medicine that had been in use for five months). Some medicines only had a label on the outer carton and not on the container itself. Staff had an up to date British National Formulary for reference. Residents confirmed that staff treated their room as their private space, and always knocked before entering. Residents’ records were being held securely. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 and 15. The standard and variety of activities has improved, and links to the community are being developed. A balanced diet is provided, with choices on the menu. EVIDENCE: Residents were aware of the activities on offer, and had a programme in their room. The activity programme was from Monday to Friday, and a discussion was held about providing some social contact and activities at weekends, particularly for those residents who did not have weekend visitors. Residents were generally very happy with the activities in the home, and participated in the activities or events that interested them. There was evidence that the activities coordinators were spending time in one to ones, with residents who preferred to remain in their rooms. However, one resident said “I would like it if staff had more time to chat”. A discussion was held about the need to record more detail about individual resident’s social contact and participation in activities. The manager confirmed that a member of the care staff was being identified to cover activities at times that the activity coordinator was absent. There was evidence of increased links with the local community. The home had received visits from local schools that had put on shows, from the Salvation Army, and from local people in the community for a musical Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 13 afternoon with cream teas. Residents and relatives confirmed that visiting was unrestricted and that visitors were made very welcome. Residents spoken with were generally very satisfied with meals in the home. A resident said, “The food is good. I have what I want and they get me something else if I don’t like it”. The dining room was attractively laid out like a restaurant. The chef confirmed that care is taken to ensure that pureed diets have an adequate nutritional content, and that each item of food was plated up in a separate compartment on the plate. The kitchen was clean and well organised. There was evidence that residents were consulted when menus were changed. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Residents are confident that any concerns would be addressed promptly. There are systems in place to protect residents from abuse. EVIDENCE: The home has complaints procedures, and procedures on the protection of vulnerable adults from abuse and whistle blowing. Residents spoken with said that they had not had any concerns or complaints that needed to be addressed, but were confident that any concerns would be acted upon. Relatives were satisfied with the standards of care, and were aware of how to raise issues of concern. Staff had received training in the protection of vulnerable adults. They had an understanding about the different types of abuse that could occur and said that they were confident about raising any concerns. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. The home is generally well maintained, but some paintwork and chairs need attention. The home is clean and residents are happy with the laundry service. EVIDENCE: Hatfield Peverel Lodge is set in attractive grounds in a residential area near Hatfield Peverel village. The two houses on the site have separate staff, and share central services such as catering, laundry and administration. The home has a rolling programme of redecoration and refurbishment. Kingfisher House was in fairly good decorative order, although some doorways had very scuffed paintwork. Some chairs were stained and others were noted to be in very poor condition. The manager said that new chairs and new bedroom carpets had been ordered, and that they hoped to replace some of the corridor carpets next year. Residents said that staff responded to call bells “fairly fast”. There were mild odours in some areas of Kingfisher House, at the start of the inspection, but they were being addressed by the domestic staff and were later noted to have improved. All residents said that they were happy with the laundry service. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 and 30. Training is being given a high priority, but staffing levels are not consistently at previously agreed levels. EVIDENCE: Staffing levels were generally at 7 nursing and care staff in the morning, 6 nursing and care staff in the evening and 4 nursing and care staff at night, which was lower than the previously agreed minimum levels of 8 in the morning and 7 in the evening. There were 35 residents in Kingfisher House at the time of inspection, and dependencies were generally high. One resident described the staff as “very competent”. Another said that the staff were very good, but considered that there were not enough care staff. There was evidence that training was being given a higher priority, and that clinical training was being given to meet the specific needs of residents in the home. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 38. Health and safety procedures in relation to accidents and equipment maintenance are not always followed. Staff are provided with training in safe working practices. EVIDENCE: In the sample of records seen it was noted that two accidents (when residents had sustained injuries) had not been recorded in the accident records. The monthly wheelchair maintenance record had only been completed three times in the previous eleven months, according to one record seen. All staff had received moving and handling and fire training. The majority of staff had started distance-learning programmes in food hygiene and health and safety. The manager confirmed that distance-learning packs were due to be distributed (in January) to all staff who had not completed infection control training. No obvious health and safety hazards were noted during the inspection. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 18 Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP4 Regulation 13(1)(b) Requirement The registered person must ensure that the resident with challenging behaviour is reassessed as to the continued suitability of their placement in Kingfisher House. Timescale for action 01/01/06 2 OP7 15 3 OP8 13(1)(b) 4 OP8 18(1)(a) The registered person must 08/11/05 ensure that care plans cover all assessed needs and are resident focused. Informed at the time of inspection. Requirement in previous reports – timescales 17.08.04 and 1.03.05 not met. The registered person must 08/11/05 ensure that residents’ mood and psychological health is monitored regularly when this an assessed need. Informed at the time of inspection. Requirement in previous report – timescale 26.01.05 not met. The registered person must 01/02/06 ensure that all nurses receive training on the prevention and management of pressure sores, and that this is cascaded to all care staff by 01.04.06. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 21 5 OP8 14(2) 6 OP9 13(2) 7 OP19 23(2)(d) 8 OP27 18(1)(a) 9 OP38 17(1)(a) 10 OP38 23(2)(c) The registered person must ensure that risk assessments are personalised to the individual resident and are reviewed and updated when residents’ condition changes. Informed at the time of inspection. The registered person must ensure that medicines are labelled on the container as well as the outer packaging. The registered person must confirm that all chairs have been cleaned, and damaged chairs have been replaced. The registered person must ensure that staffing levels are kept at the agreed minimum levels. The registered person must ensure that all accidents are documented on an accident form. Informed at the time of inspection. The registered person must ensure that safety checks are regularly carried out on equipment such as wheelchairs. Informed at the time of inspection. 08/11/05 01/02/06 01/01/06 01/01/06 08/11/05 08/11/05 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 OP3 Good Practice Recommendations The registered person should ensure that the preadmission assessment process covers all aspects of standard 3.3. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, 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 Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V266145.R01.S.doc Version 5.0 Page 23 - 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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