CQC report explained · a residential care home
What the CQC found at Hapstead Village
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- There were not always enough staff to meet people's needs, and inspectors saw staff using face coverings incorrectly or not wearing them. Recruitment, medicines and general risk assessments were otherwise described as safe.
- Effective?
- Requires improvement
- People were not always supported to make their own decisions, because mental capacity assessments and best-interest decisions were missing. Staff training, healthcare support, food and the environment were otherwise positive.
- Caring?
- Good
- Staff were kind and compassionate, respected people's dignity and understood their communication styles. People were encouraged to make decisions about their care and remain independent.
- Responsive?
- Good
- Care plans described people's needs, strengths, routines and preferences. People were supported with communication, activities, voluntary work, community life and relationships.
- Well-led?
- Requires improvement
- There was a positive culture and good teamwork, but governance systems had not found problems with consent, safeguarding and reporting significant events. The provider had not notified CQC about an important event.
What inspectors found, July 2022
Hapstead Village is rated Requires Improvement; inspectors found kind, personalised care but concerns about staffing, infection control, consent and management.
Inspectors visited over three days in May 2022. They spoke with eight people and seven staff, reviewed ten care records and checked medicines, staff records and quality systems. They also sought information from professionals and the local authority.
The home was caring and responsive. Staff were kind, knew people well and supported people to communicate, make choices, stay active and keep relationships. Medicines were managed safely, and healthcare referrals were made promptly.
However, there were not always enough staff to support people's usual activities. Inspectors also found incorrect use of face coverings, missing mental capacity and best-interest records, and weaknesses in reporting and quality checks. The overall rating fell from Good at the previous inspection to Requires Improvement.
Kind and respectful staff
Inspectors saw kind and compassionate interactions. Staff knew people well and used respectful language.
“Throughout our inspection we witnessed staff being kind and compassionate towards the people they supported and showed they had formed a strong relationship with people and knew them well.” from the report
Personalised support
Most people received flexible support from staff who understood their needs. Care plans included people's skills, strengths, routines and preferences.
“Support plans were informative and described people's skills and strengths as well as the support needed from staff and/or other services.” from the report
Support for independence
People were supported to make choices, go into the community and take part in activities and voluntary work.
“Throughout our inspection we saw people coming and going as they wished, this included going out into the local town with or without staff support.” from the report
Safe medicines support
Staff administered, recorded, stored and disposed of medicines safely. People were supported to be involved in preparing medicines and, where possible, to self-administer.
“People were supported by staff who administered, recorded, stored and disposed of medicines safely.” from the report
Infection control
seriousInspectors saw staff from four homes wearing face coverings incorrectly, using the wrong type or not wearing one. This increased the risk of infection spreading.
“Throughout the inspection we observed staff from four homes on the campus not wearing face masks correctly; wearing the wrong type of face covering and, in some cases not at all.” from the report
Consent and restrictions
seriousRecords did not show that people's capacity had been assessed or that best-interest decisions had been made for decisions about money, medical care and access to snacks.
“The failure to assess people's capacity and record best interest decisions risked compromising people's rights.” from the report
Weak quality checks
needs fixingThe provider's monitoring systems had not identified problems with consent, safeguarding and significant event reporting. This reduced confidence that issues would be found quickly.
“The systems in place to monitor the quality of service were not always effective.” from the report
Important event not reported
seriousThe provider had not notified CQC about a significant event, although inspectors found no evidence that people had been harmed and the provider acted after this was raised.
“However, we found the provider had not notified the Care Quality Commission of a significant event, which had occurred.” from the report
- 01What changes have been made to staffing levels, and can you show how people now get support for their usual community activities?
- 02How are staff checked to make sure they use infection control measures and face coverings correctly?
- 03How do you assess a person's capacity before managing their money, food or other choices?
- 04Where a decision is made in someone's best interests, how are the reasons, consultation and legal authority recorded?
- 05How do your current quality checks identify safeguarding concerns, consent problems and events that must be reported to CQC?
This inspection covered the care home, including its premises and personal care, and personal care in two supported living settings; CQC did not regulate the supported living premises. This explanation was written from the published report of 30 July 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2019
Hapstead Village was rated Good; inspectors found safe, kind and personalised care, with some improvements needed in incident records and support with personal appearance.
This was an unannounced inspection. Inspectors visited five of the six buildings, spoke with people, relatives, staff, volunteers and health professionals, and checked care plans, medicines records, staff files, rotas and other records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe and well cared for. Inspectors saw staff supporting people respectfully and helping them make choices, stay active and be as independent as possible.
The inspection found enough staff, suitable recruitment checks, regular staff training and safe medicines systems. Care plans were generally detailed and up to date. However, learning from incidents was not always shared between houses, some incident records used language that sounded punitive, and one person had not received enough support with their appearance. The home acted on these issues after the inspection.
Personalised lives
People were supported to make choices, take part in varied activities and develop their independence. The home offered rural tasks, craft workshops, community outings and holidays.
“In Hapstead Village we found that people received personalised care, were supported to be as independent as possible and lived varied and interesting lives.” from the report
Kind relationships
People and relatives described staff as kind and caring. Inspectors saw people approaching staff confidently for reassurance and support.
“The atmosphere in each house was relaxed and informal.” from the report
Safe staffing and medicines
The home had planned staffing levels, recruitment checks and trained staff. Medicines records were complete and medicines were received, stored and given safely.
“Medicine Administration Records (MAR) were fully completed and had been regularly audited.” from the report
Good oversight
Managers had clear responsibilities and used regular audits, feedback and action plans to monitor the service and make improvements.
“The service's quality assurance systems were appropriate and designed to drive improvements in performance.” from the report
Incident learning
needs fixingManagers investigated incidents, but information was not always shared with the registered manager or between houses. This meant learning might not spread across the home.
“There was a lack of consistency in how details of incidents were shared with the registered manager and this meant some learning may not have been appropriately shared across the service.” from the report
Incident record language
needs fixingSome incident records sounded as if staff had responded punitively. Inspectors found that the actual support given to people was appropriate, and new procedures were introduced.
“The tone and style of some incident records gave an impression that staff had responded punitively to incidents that had occurred.” from the report
Safeguarding reporting
needs fixingStaff knew how to raise concerns with managers but were not entirely clear about reporting concerns outside the home. The manager said extra guidance would be provided.
“Although information on how to raise concerns outside the service was displayed on notice boards throughout the service staff were not entirely clear on how to report issues outside the service.” from the report
Personal appearance support
needs fixingOne person receiving supported living care had not received the support set out in their care plan to maintain their appearance. The care plan was updated and extra support arranged after the inspection.
“We were concerned this person's needs were not being met and raised this with the registered manager and the care manager at the end of our inspection.” from the report
- 01How are the new procedures ensuring that every accident and incident is reported to the registered manager and learning is shared between houses?
- 02What guidance do staff now have about reporting safeguarding concerns outside the home?
- 03How do you check that each person's care plan is being followed, including support with personal appearance?
- 04How will you support the person I care for to choose activities, outings and community opportunities?
- 05How are people's views collected through residents' meetings, questionnaires and the independent advocacy service?
This was an unannounced inspection of all five key questions, covering the care home premises and personal care, and personal care in the supported living settings; the premises used for supported living were not regulated by CQC. This explanation was written from the published report of 17 January 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Hapstead Village
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- July 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 3 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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