Care Home: Hatfield Peverel Lodge Residential and Nursing Home

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What the care home does well Hatfield Peveral is well managed and people who live there receive good care and support. Residents and relatives have access to information about the home to help them decide if it will be suitable for them. Staff assess each person needs before offering a place at the home. Each person living in the home has a care plan developed so that staff have information to provide a consistent level of care and support. Residents have their medical and care needs met. Staff assess risks to residents health and safety and take action to minimise these. Residents are treated with respect and enabled to make decisions and choices about their daily lives. A good range of activities is provided for residents. The home is clean and comfortable and checks are carried out equipment so as to ensure that it is maintained in safe working order.The staff team receive support and training and care practices are monitored. Staff and residents enjoy positive relationships and there is a welcoming feel to the home. People who live in the home and their relatives have spoken very positively about the staff and manager. A number of residents have commented that they are happy living there. What has improved since the last inspection? The manager and staff team have worked very hard to comply with the requirements made at the last inspection. A new system for recording information has been introduced. There have been improvements made in how information about resident`s medicines is recorded. The manager now carries out rigorous checks on people before they are employed by the home and the induction programme has bee restructured so that all new staff will be better equipped to care for residents. There have been improvements made so as to ensure that residents receive nutritionally balanced meals and there are hot and cold food snacks available 24 hours a day. Residents and relatives are happy with the care provided by the home. What the care home could do better: Staff could record more information individualised about residents needs in care plans to ensure that wishes and choices are taken into account when providing care. Staff on Mallard could be more consistent in the support provided at mealtimes. Staff rotas should be completed accurately so as to reflect who is working at the home at all times and staff should have more training regarding the safeguarding of residents from harm or abuse. Information about the arrangements for resident`s bank accounts and how they can access their money should be clearly recorded and available. CARE HOMES FOR OLDER PEOPLE Hatfield Peverel Lodge Residential and Nursing Home Crabbs Hill Hatfield Peverel Chelmsford Essex CM3 2NZ Lead Inspector Carolyn Delaney Unannounced Inspection 12th February 2008 10:00 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.V346240.R01.S.doc Version 5.2 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.V346240.R01.S.doc Version 5.2 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 fergusonc@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited 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) Mrs Sau Kaun Ferguson 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.V346240.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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) The total number of service users accommodated must not exceed 71 persons 2. 3. Date of last inspection Brief Description of the Service: Hatfield Peveral 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 Peveral Lodge is located approximately half a mile from the centre of Hatfield Peveral 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 Peveral is on the main London to Colchester train route. The current weekly fee ranges from £600 to £850 per week. Additional charges/costs are incurred by residents relating to chiropody hairdressing and personal items such as newspapers etc. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was routine key inspection. As part of the inspection process an unannounced visit was made to the home. During this visit residents, relatives and staff were spoken with and a number of records such as care plans, staff records and information about how the home is managed and maintained were assessed. A brief tour of the home was carried out and communal areas such as dining rooms and lounge areas were viewed as well as a number of residents bedrooms. Prior to the inspection visit the manager provided the Commission with a copy of their Annual Quality Assurance Assessment (AQAA). This document included information as to what they do well, what could be done better and what needs improving. As part of the inspection process a number of residents and relatives were offered the opportunity to make comment about the home by completing feedback surveys. What the service does well: Hatfield Peveral is well managed and people who live there receive good care and support. Residents and relatives have access to information about the home to help them decide if it will be suitable for them. Staff assess each person needs before offering a place at the home. Each person living in the home has a care plan developed so that staff have information to provide a consistent level of care and support. Residents have their medical and care needs met. Staff assess risks to residents health and safety and take action to minimise these. Residents are treated with respect and enabled to make decisions and choices about their daily lives. A good range of activities is provided for residents. The home is clean and comfortable and checks are carried out equipment so as to ensure that it is maintained in safe working order. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 6 The staff team receive support and training and care practices are monitored. Staff and residents enjoy positive relationships and there is a welcoming feel to the home. People who live in the home and their relatives have spoken very positively about the staff and manager. A number of residents have commented that they are happy living there. What has improved since the last inspection? What they could do better: Staff could record more information individualised about residents needs in care plans to ensure that wishes and choices are taken into account when providing care. Staff on Mallard could be more consistent in the support provided at mealtimes. Staff rotas should be completed accurately so as to reflect who is working at the home at all times and staff should have more training regarding the safeguarding of residents from harm or abuse. Information about the arrangements for resident’s bank accounts and how they can access their money should be clearly recorded and available. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 8 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.V346240.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home and the assessment process assures residents that the home will be able to meet their needs. EVIDENCE: From the AQAA we were informed that the people are assisted in choosing a suitable home in Hatfield Peverel by providing information about the home and carrying out a comprehensive assessment of each persons’ needs. The manager said that rates are competitive compared to homes providing a similar service. There is a detailed statement of purpose document, which clearly describes the aims and objectives of the home and the range of services provided. In addition each person and or their relatives are provided with a copy of the home’s service users guide which describes life in the home and gives detailed Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 10 information about areas such as laundry service, meals, opportunities for activities and religious services etc. All of the residents and relatives who completed surveys said that they had received enough information about the home so enable them to make a decision about moving in. One person commented that they had viewed the home and had a discussion with the manager before deciding to move in. Since the last inspection BUPA have introduced a new format for recording information about residents needs. This includes an assessment, which staff complete for prospective residents. The assessment for the person most recently admitted to Kingfisher and Mallard units were assessed. The manager had completed a detailed assessment of both these persons’ nursing and care needs. There was evidence that the resident and relatives had been involved in the assessment. Once a person moves into the home the information in the initial assessment is reviewed and amended where there have been any changes. This ensures that there is up to date and accurate information about each person from which to develop a plan of care. The results of recent resident and relative satisfaction surveys carried out by BUPA show that 71 of relatives and 100 of residents who participated were happy with the home. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. While there are some shortfalls in recording, outcomes for residents are good and they receive care and support appropriate for their needs. EVIDENCE: The manager told us in the AQAA that all residents have a person plan developed, which is individual to the persons identified needs. The care plans for a selection of residents on both units were examined. Some care plans did not include specific information about resident’s individual needs. For example where daily care records indicate that a resident was very noisy at night and did not sleep well, the night care plan did not reflect this. Where some residents were confined to bed their mobility care plans did not reflect this. Some care plans did not reflect resident’s views or how their needs affected their ability to carry out daily activities. Despite the shortfalls in recording, residents receive a good level of care and support. Where risks have been identified in respect of the health and safety of residents these were very well managed. Records indicate that falls and Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 12 accidents are monitored to identify any trends so as to plan to minimise these. One person had developed a pressure sore whilst in the home. There was evidence that this had been treated appropriately and that specialist advice had been sought and acted upon. Residents looked well cared for, in particular residents who depend upon staff for ensuring that they are kept clean and comfortable. Staff ensure that residents hair nails and mouth care is well maintained. Where residents require assistance with changing their position in bed, taking food and fluids there was evidence that they are well supported. All residents were wearing suitable clothing and footwear. Residents and relative who completed surveys and who spoke with the inspector were very positive about the care and support that residents receive. All of the residents who completed surveys feel that they receive the medical attention and care that they need. Records were kept regarding visits made by residents general practitioner’s and there was evidence that where specialist advice or input was appropriate, that this was sought. Records are maintained regarding the medication, which is prescribed for residents. These records were well maintained in line with the proprietor’s policy. Staff were observed to administer medicines in a safe manner. Wherever it is possible residents are supported to retain control of their medicines. Procedures for storing medicines were noted to be safe and appropriate. All of the residents who completed surveys said that staff listen and act on what they say. A number of relatives commented that staff encourage residents to make choices such as asking when they would like to use the toilet, what food they would like and what activities they would like to participate in. Residents and relatives feel that staff provide good care and a number of people said that they were happy living in the home. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff working at the home enable and support residents in making decision about their daily lives and activities. EVIDENCE: From the AQAA we were told that residents have opportunities to access a range of activities and that relatives are received in a friendly way and able to join in activities. Relatives who were spoken with during the inspection confirmed this. Relatives were welcomed into the home and offered refreshments. Some relatives took meals with residents. All of the residents who completed surveys said that there are activities arranged that they can take part in. Activities are planned on a weekly basis and are displayed throughout the home. Care staff undertake an introduction to activities training as part of their induction and are actively involved n promoting activities as part of daily living. During the inspection visit, residents were observed to participate in flower arranging, seated exercises to music and a sing a long with music provided by one residents’ relative. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 14 Residents appeared to enjoy the activities provided. Residents were offered the choice about how they wished to spend their time and there was evidence that the activities coordinators regularly speak with residents so as to help enable them to provide activities, which they will enjoy. There was evidence that activities are provided during some evenings and some weekends. A number of excursions had been arranged for residents including trips to the local seafront, jam factory and theatre. Staff aim to have an outdoor trip for residents on alternative months. The manager intends to introduce a satisfaction survey for residents to see where improvements can be made. People who completed surveys said that the needs of different people are met regarding issues such as race, age, sex and faith. Two relatives who spoke with the inspector commented on how the staff cater for the individual needs of residents. There are opportunities for residents to attend religious services according to their faith. A number of residents said that they were ‘very happy’ in the home. Throughout the inspection staff were observed to ask residents what they would like to do and one resident commented that they were very happy and that staff ‘do not make assumptions about what they want.’ Residents who were spoken with and who completed surveys said that they generally enjoy meals provided. BUPA have introduced a menu master system so as to ensure that meals meet the nutritional needs of residents. A new ‘Night Bite’ menu has been introduced so that food is available 24 hours a day. During the inspection the serving of meals was observed. Residents were offered a choice of meal and had the opportunity to have an alternative choice if they had changed their mind about what they had ordered. The more able residents can help themselves to a choice of condiments and sauces and some other residents were offered these. Some relatives joined residents. Meals were served to residents in dining rooms or if they chose in their bedrooms. The mealtimes were unrushed and staff were generally available to assist and support residents. The manager had identified in the AQAA need to review deployment of staff on Mallard at mealtimes due to the high number of residents who need support. The serving of the lunchtime meals was observed and staff worked hard to support residents. It was noted that on Mallard some residents were not offered the choice of condiments or sauces and residents seated at tables were not served meals together. This may detract from residents experience and overall enjoyment of their meals. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems, including policies and procedures and robust recruitment practices, help to safeguard people living in the home and assure them that complaints are taken seriously. EVIDENCE: From the AQAA we were informed that there had been eleven complaints made within the previous twelve months. Of these 81 had been resolved within twenty-eight days. Of these complaints three had been upheld. There is a clearly defined complaints policy which residents; relatives and other visitors have access to. All of the residents and relatives who completed surveys and who spoke with the inspector confirmed that they knew who to speak to if they were unhappy or needed to make a complaint. People who spoke with the inspector said that they would usually raise any issues with the manager and feel confident that these would be resolved. The few people who indicated that they had complained said that they were satisfied with how the complaints were dealt with. A record of complaints received was available for inspection and this evidenced that complaints are dealt with in accordance with BUPA’s policy. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 16 The AQAA indicated that there had been no allegations regarding the safeguarding of residents at the home within the previous twelve months. All of the people who were spoken with commented on the kindness of staff. Safeguarding awareness training has now been incorporated into the induction programme for all new staff and management of challenging behaviour is included in the induction for staff working on Mallard unit. Staff who were spoken with during the inspection could demonstrate that they knew what action to take if they witnessed or suspected any ill treatment of residents. From the staff training matrix it was noted that while all staff working at the home had received safeguarding training, some staff had not received training since 2005. This could potentially put residents at risk. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hatfield Peverel Lodge provides safe, comfortable and well-maintained home for residents. EVIDENCE: From the AQAA we were told that the home is maintained free from unpleasant odours and that residents and visitor have access to accommodation, which is pleasantly decorated and furnished. A specialist micro fibre cleaning system is used, which has reduced the need for the use of chemicals in the home. All of the residents and relatives who spoke with the inspector indicated that they were very happy with the accommodation. During the inspection a tour of the premises was carried out. All areas were noted to be clean and there were no unpleasant odours. Resident’s bedrooms, which were seen, were comfortable and personalised. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 18 A dedicated team of cleaning staff are employed in the home and the majority of people who completed surveys said that the home is fresh and clean. Residents have access to a large activities room, which is equipped with books, puzzles and games. Residents living on Mallard have access to a secure sensory garden and one bathroom has been developed into a sensory bathroom with mood lighting, music and aromatherapy. Staff said that this has proved popular with residents. Some work has been carried out in the grounds of the home to provide more seating so that residents can benefit from the beautiful rural surroundings. During the inspection residents and relatives spent time in the garden, which they said, they enjoyed. Some areas of the home were noted to be in need of redecoration however this does not detract from the overall comfort of the home. In the AQAA the manager acknowledges that the redecoration programme for bedrooms could be improved, as could the provision of storage space for equipment such as hoists. Records evidenced that checks are carried out for all equipment used in the home so as to ensure that it is suitable and safe for residents use. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The consistent recruitment process and staff training programme help to assure residents that they will be cared for by suitable and competent staff. EVIDENCE: From the AQAA we were informed that relationships between staff and residents were positive. We were also told that staff recruitment had improved and that there was a more structured induction programme in place. This was confirmed during the inspection visit. All of the residents who completed surveys said that staff are available when they need them. Staff rotas indicated that staffing levels at the home are maintained and that staff have appropriate off duty time. It was identified at the previous inspection that staff duty rotas did not always include the full name of staff working at the home or temporary agency staff. The staff rotas evidenced that staff names are not being recorded in full and this was brought to the manager’s attention. While this does not impact upon the care received by residents it is not good record keeping practice. Five members of staff who were spoken with during the course of the inspection said that they felt supported and a number of staff said that they really enjoyed working at the home. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 20 During the inspection staff on both units were observed to spend time chatting with residents and there was a warm and welcoming atmosphere on both the units. Residents and relatives who completed surveys and who spoke with the inspector made positive comments about staff. One person said that ‘staff are supportive and take a genuine interest in residents’. Another person commented that ‘the home is very good and staff are very helpful’. A training matrix was provided by the manager and this evidenced the wide ranging training programme for staff which includes core training such as health and safety, safe moving and handling, fire safety and safeguarding. In addition staff undertake training including providing activities for residents, managing aggression, palliative care and medication training. Five members of care staff have completed National Vocational Training (NVQ) and a further eight staff undertaking the training at the time of this inspection. Each of the relatives who completed surveys said that staff have the right skills and experience to look after people properly. The recruitment files for four people who had commenced work at the home since the last inspection were examined. There was evidence that for each person that rigorous checks had been undertaken so as to determine that the person would be suited to working in the home. References had been obtained from previous employers and satisfactory Criminal Records Bureau (CRB) disclosures had been undertaken. In addition the home’s manager had interviewed each person. Upon commencing work at the home all staff had undertaken a period of induction, which included supervised practice and training in moving and handling, health and safety, safeguarding people from abuse etc. Care staff complete a workbook based upon the skills for care induction. Registered nurses complete a qualified nurse portfolio and have a period where a senior nurse mentors them. A number of people commented in surveys about the high staff turnover at the home and the impact it has on the continuity of care. From the AQAA we were informed that seven fulltime and sixteen part time staff had left employment in the past twelve months. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hatfield Peverel Lodge is managed in an open and positive manner. Residents and relatives feel that the staff at the home meet their needs. EVIDENCE: A new manager had been employed at the home since the last inspection. The Manager has been registered with the Commission during this time. From the AQAA we were told that there is an effective quality assurance system in place and that the manager has an open style leadership. There was evidence that the home is well managed and that residents and relatives are regularly consulted about how the home is managed and that their views are taken into account when planning changes. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 22 The results of recent resident and relative satisfaction surveys carried out by BUPA show that 71 of relatives and 100 of residents who participated were happy with the home. The operations manager has recently started to carry out regular quality and compliance audits. This includes regular checks for auditing medication, health and safety, recruitment and training practices within the home. Records reflect the positive findings as described within this report. Residents, relatives and staff all made very positive comments about the home’s manager and people feel that any issues raised will be resolved. BUPA’s operations manager visits the home regularly to carry out assessments of the home in accordance with Regulation 26 of the Care Homes Regulations and reports in respect of these visits are sent to the Commission each month. People living at the home have the opportunity to have their money banked in an interest bearing bank account. Residents who chose to do this do not have an individual account, however the rate of interest applied to their account is calculated in proportion to their account balance. Residents do not have access to money at weekends or evenings. The homes administrator said that this has never been an issue. There was evidence that staff working at the home receive regular supervision so as to monitor and maintain quality in staff practice. Staff spoken with confirmed that they receive regular supervision and support. Records and certificates in respect of the maintenance, repair and renewal of systems and equipment in the home were examined. These were organised, up to date and evidenced that all equipment including fire safety, gas and electrical installations were maintained in good working order. We were told in the AQAA that regular Health and Safety meetings are held and the home has the back up of the organisations policies, procedures and a team of staff within BUPA’s Quality and Compliance Directorate. Incidents of pressure sore development and accidents / injuries to residents are monitored so as to identify any trends and to make plans to minimise these. Records are well maintained Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 24 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 OP27 Regulation 17 Requirement The staff duty rotas must include the full names of people employed at the home. Timescale for action 30/03/08 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. 2. Refer to Standard OP7 OP15 Good Practice Recommendations Residents care plans could be more person focused and contain more specific information about resident’s needs and the support they need. More could be done to ensure that residents on Mallard are offered choice of condiments/ sauces with meals and that they receive their meals together so as to enhance their enjoyment of meals. All staff working at the home should undertake periodic updates in respect of safeguarding residents from harm or abuse. The programme for redecoration of resident’s bedrooms could be improved. The arrangements for resident’s access to monies held for DS0000015350.V346240.R01.S.doc Version 5.2 Page 25 3. 4. 5. OP18 OP19 OP35 Hatfield Peverel Lodge Residential and Nursing Home them by the home should be clear and included within the service users guide. Hatfield Peverel Lodge Residential and Nursing Home DS0000015350.V346240.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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