Hatfield Peverel Lodge Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The assessment was carried out following concerns raised with the local authority and the Commission by staff. The provider responded proactively to these concerns, and an independent member of the senior operations team was working with staff to ensure they felt confident raising issues internally. This included ongoing staff listening sessions.

Although we identified some infection control issues during our visit, we found that the management team had responded proactively to our feedback and had taken steps to strengthen their processes at the service.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked well with other professionals. The GP visited people at the home on a weekly basis and people were referred to specialist services if needed in a timely manner. Care plans showed evidence of outpatient appointments with specialist nurses, such as stoma or diabetic nurses, with outcomes recorded to ensure up-to-date information.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. Any conditions related to DoLS authorisations were being met.

The registered manager and deputy manager maintained oversight of all safeguarding concerns at the service. Any concerns were reported to safeguarding authorities, and all actions taken were recorded on an electronic system, which was reviewed by the senior quality team to ensure any outstanding actions were completed. All incidents were investigated using a root cause analysis process.

People told us they felt safe at the service. One person said, “I have been here over a year; it is safe- everybody looks after things.” Another person said, “Of course I am safe.”
Staff demonstrated a clear understanding of safeguarding reporting processes. One staff member said, “I would talk to my line manager or the home manager and use the speak-up service.” Another added, “If I ever suspected someone was being abused or at risk, I would follow the safeguarding policy straight away: make sure the person is safe, report it to the nurse or manager, and document it properly. If it were not acted on, I would escalate it to higher management or the safeguarding authority. We are encouraged to speak up about poor care, and I feel safe to do so.”
 

The provider worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff undertook risk assessments in consultation with people using the service. Care plans showed that people were actively involved in managing risks related to their health and wellbeing. Risk assessments were regularly reviewed and included guidance for staff, reflecting each person’s preferences and wishes. For example, one person with a stoma [a stoma is an opening on the surface of the abdomen which has been surgically created to divert the flow of faeces or urine] was supported to self-manage, while another with fluctuating mobility was encouraged to use a walking frame. Another person told us they were now able to attend their own hospital appointments independently, following previous support from staff.

However, 1 person’s care plan indicated they required staff supervision when walking. During our observations, we saw this person walking without supervision. When we spoke with the registered manager, they informed us that the person’s care was being reviewed with commissioners to determine whether additional support was needed.

Staff reported having the information they needed to provide safe care to people. One staff member said, “If I identify changes in a resident’s needs, I carry out the necessary assessment, document the changes in their notes, and review the care plan. Then I communicate this to the team through handover or the 10:10 meeting, which we hold daily.”
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Processes were in place to manage environmental risks, and regular checks were carried out covering fire, gas, and water safety. Personal Emergency Evacuation Plans (PEEPs) were in place for each person, outlining the support they would need in an emergency. Fire drills were conducted regularly and involved all staff. Equipment used to assist people with moving had been serviced and was safe to use.

We did identify issues with a broken radiator and taps that required descaling; however, these were followed up and addressed by the second day of our visit.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff were not always deployed appropriately.

We observed that sufficient staff were available overall, however, during the afternoon of day 1 of our assessment in the area where people were living with dementia, we were not assured that suitable support was available for people on the second floor of this area. For a 30-minute period, no qualified staff were present, and the only staff member on the floor was a housekeeper. The housekeeper informed us that care staff were on their breaks. We immediately fed this back to the registered manager and deputy manager, who confirmed this should not have occurred and committed to investigating the gap in staff deployment.

Overall, most people and relatives were satisfied with staffing levels. One person told us, “It is not bad, I am looked after very well. When I use the buzzer, they are quite quick.” A relative said, “I feel they are mostly coping. At lunchtime, there is always one staff member in the lounge, but when the one-to-one staff member is on their break, the room carer is stretched.”

Staff we spoke with felt there were enough staff to meet people’s needs. One staff member said, “Yes, enough staff if the team is organised. Staffing numbers at weekends are the same. If someone calls in sick, they will cover with agency if needed—however, we have not used agency for a long time.” Another staff member added, “I think there are enough care staff. We have more now and no agency.”

A professional did give us feedback about one area of the service where they were not assured about the staffing levels in the nursing area as felt people had not always been supported with personal care very early. We fed this back to the registered manager.

As noted in the infection prevention and control section of the report, where concerns were identified, we discussed the levels of housekeeping staff at the service. The registered manager followed up on these concerns and told us that while vacant hours were being covered, they would be reviewing staffing levels with senior management to identify areas for improvement.

People were supported by staff who had been safely recruited. Oversight of training was in place to ensure staff received the training they required to undertake their role.
 

The provider did not always assess or manage the risk of infection appropriately. They did not always detect and control the risk of it spreading. They did share concerns with appropriate agencies promptly.

Whilst most parts of the service were clean, we noted 1 kitchen with a very dirty air conditioning unit. A bathroom where equipment had been tagged as clean but was not clean, toilet brushes that needed replacing and a stained carpet in 1 of the main communal areas. Infection control audits had identified some of these concerns, however, we were concerned some of the dates for completion of these actions were too far ahead. If cleanliness issues in a care home are not addressed quickly, they can pose risks to people or staff.

Most of the issues we identified on day 1 of our assessment had been rectified by day 2 and the provider had taken additional action to prevent reoccurrences. Infection control audits which were previously being carried out quarterly will now be completed monthly. These monthly audits will now be embedded and discussed into the weekly clinical risk meetings and additional refresher training will be provided to housekeeping staff by senior staff. In response to the feedback the service received from us during the assessment, the provider told us greater emphasis will now be placed on the urgency of action plans, with careful consideration given to the time allocated for each action and its priority level.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Weekly and monthly audits of medicines were conducted by unit managers, the registered manager, and the regional manager. As-required medicines (PRN) and homely remedies were reviewed monthly. However, the audits had not identified unlabelled creams we found in several people’s rooms during the assessment. Senior staff removed these immediately, and locked boxes were provided for people’s rooms during our visit.

Medicine administration records were completed and signed, and reconciliation of medicine stock levels were accurate.

Staff had received training in medicines administration and were assessed for competency. A spreadsheet was used to track the completion of training and competency assessments.

People told us they received their medicines on time. One person said, “I have my meds five times a day—none are missed. The nurses are kind.”