CQC report explained · a nursing home
What the CQC found at Hatfield Peverel Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Hatfield Peverel Lodge Care Home was rated Good; inspectors found people safe and the home well managed, with some management changes still under way.
The inspection was unannounced. Inspectors visited on 7 and 9 December 2022, spoke with relatives and staff, observed people's care, reviewed care and recruitment files, and checked the home's records and audits.
Inspectors found enough suitably trained staff, safe medicines practice, good infection control and detailed risk assessments. Incidents and complaints were investigated, and the home worked with health and care professionals to support people's wellbeing.
The home did not have a registered manager during the inspection. A new manager had been recruited and was undergoing checks. A medicines fridge and a stair lift had problems, but these were dealt with during the inspection.
The overall rating improved from Requires Improvement at the previous inspection to Good. This inspection looked at Safe and Well-led. Ratings for other areas were carried forward from the previous comprehensive inspection.
Safe staffing
Inspectors observed enough staff to meet people's needs. The home had recruited more permanent staff, reducing its use of agency staff.
“We observed there was enough staff to meet people's needs.” from the report
Medicines
Staff were trained and administered medicines safely. Records were accurate, people's consent was sought and medicines were audited weekly.
“Staff managed and administered medicines in a safe and competent way, ensuring all details were accurately recorded, and they sought peoples consent before administering.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements to prevent and manage infections, including the safe use of protective equipment.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Management oversight
The home used audits and monthly incident reviews to identify actions and track who was responsible for completing them.
“Monthly reviews of incidents looked for themes and trends to help create action plans to improve systems and services.” from the report
Listening to families
Relatives were regularly asked for their views about people's care and the home as a whole. Complaints were investigated and answered promptly.
“People's relatives and loved ones told us they were regularly asked for their input into people's care, and the service as a whole.” from the report
No registered manager
needs fixingThere was no registered manager in post during the inspection. A new manager had been recruited, but pre-employment checks were still being completed.
“At the time of our inspection there was not a registered manager in post.” from the report
Medicines fridge
needs fixingA medicines fridge had broken and medicines had been moved to a fridge on another floor. A replacement had been ordered and the issue was fixed on the second inspection day.
“A medicines fridge had broken, and all medicines had been moved to a fridge on another floor.” from the report
Equipment faults
minorA stair lift was not working on the first day of inspection. It was repaired the same day, while another lift was being refurbished.
“On the first day of inspection, a stair lift was found to be not working, this was repaired the same day.” from the report
Recent agency staffing
needs fixingStaff had previously raised concerns about consistent care because of high agency staff use. The home had since recruited more permanent staff and reduced agency use.
“Concerns around consistent care were raised by staff earlier in the year, due to high agency staff usage.” from the report
- 01Has the new manager completed the required checks and taken up the registered manager role?
- 02How do you monitor staffing levels and make sure the reduction in agency staff is maintained?
- 03What checks are now in place to make sure medicines fridges and other essential equipment remain working?
- 04How are monthly incident reviews and audit actions shared with families and staff?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led, including infection control; the other key-question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 17 January 2023 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, April 2021
Rated Requires Improvement; inspectors found caring staff and enough staff at the visit, but gaps in risk records and management oversight left some safety risks.
The inspection was unannounced and followed concerns about management and staffing. Inspectors spoke with people, relatives, staff and health professionals. They observed care and reviewed care, medicine and staff records.
The home had enough staff when inspectors visited, and people were supported by caring staff who knew them well. Medicines were generally managed safely, and staff worked well with outside professionals. However, some care plans did not contain enough information about people's specialist needs and risks.
Management checks, records and staff supervision had not always been completed or acted on. Staff morale was low, and some staff did not feel confident that concerns would be treated confidentially. The overall rating fell from Good at the previous inspection to Requires Improvement.
Caring staff
Staff were described as warm and person-centred. Relatives and professionals were mainly positive about the care people received.
“Every member of staff and management we spoke to was person-centred and spoke of people warmly.” from the report
Staff available at inspection
There were enough staff to support people safely during the inspection. Staff responded quickly and kindly to requests for help.
“There were now enough staff to support people safely. We observed staff respond quickly and kindly to requests for help.” from the report
Working with professionals
The home worked positively with health and social care professionals when people needed additional support or treatment.
“Professionals described a positive working relationship focused on people's wellbeing.” from the report
Medicine storage
Medicines were safely stored and organised. Staff knew people well and could describe the support individuals needed.
“Medication was safely stored in a locked room and there was no excessive stock.” from the report
Incomplete risk information
seriousSome care plans did not contain enough information about specialist needs, including diabetes, fluid restrictions and mattress settings. This could put people at risk when supported by staff who did not know them well.
“There were gaps in some people's care plans around specialist needs and risks.” from the report
Checks were not always followed through
needs fixingSome quality checks had identified actions, but these were not dealt with promptly. Repairs and care plan gaps had not always been properly assessed and prioritised.
“Where checks had highlighted actions were needed, we found some had not been addressed in a timely manner.” from the report
Low staff morale
needs fixingStaff described feeling poorly supported and some were reluctant to speak out. Concerns about confidentiality had already been raised but remained part of the improvement work.
“Staff morale was low, largely due to the devastating impact of the COVID-19.” from the report
Infection check at entrance
needs fixingThe checks carried out when inspectors arrived did not follow the provider's policy, although checks at another entrance were being carried out safely.
“When we arrived at the service, checks were not carried out in line with the provider's policy.” from the report
Medicine guidance
seriousWritten guidance was not always personalised. There was insufficient guidance for one person with epilepsy, creating a risk if unfamiliar staff provided support.
“We found one example where there was insufficient guidance in place for a person with epilepsy.” from the report
- 01How do you check that every person's care plan contains current information about specialist needs and risks?
- 02How will temporary and agency staff be given enough information to support people safely during staff shortages or an outbreak?
- 03What has changed to improve nursing staff retention and cover at weekends?
- 04How are you monitoring staff morale and making sure concerns can be raised confidentially?
- 05What repairs and infection control improvements have been completed since the inspection?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key questions were not assessed and no ratings were given for them. This explanation was written from the published report of 23 April 2021 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 Hatfield Peverel Lodge Care Home
7 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- January 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Hatfield Peverel Lodge Care Home →
- April 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Hatfield Peverel Lodge Care Home →
- November 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2017Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 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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