Hapstead Village was rated Requires Improvement overall, with breaches identified in infection control (PPE), staffing levels, consent/MCA, good governance and failure to notify CQC of a significant event. Caring and responsive aspects remained Good, with positive person-centred culture, safe medicines management and strong staff relationships.
Concerns (7)
critical
Infection control
: “We were not assured that all staff were using PPE effectively, safely and in line with best practice guidance.”
criticalStaffing levels: “There were not always enough staff to meet people's needs effectively. The provider had identified this and were taking action to address staffing levels.”
criticalConsent / capacity: “The failure to assess people's capacity and record best interest decisions risked compromising people's rights.”
criticalGovernance: “The failure to operate fully effective systems to continuously assess and improve the quality of the service was a breach of regulation 17”
criticalOther: “the failure to notify CQC of a significant event was a breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009.”
moderateSafeguarding: “the provider had failed to inform the local safeguarding authority following an incident at Hapstead village... they had failed to make a timely referral to the local authority.”
minorSupervision / appraisal: “due to the impact of the pandemic on staffing levels, they had not managed to fully complete their normal supervision processes/records.”
Strengths
· People were supported by staff who administered, recorded, stored and disposed of medicines safely, with STOMP principles implemented.
· Safe recruitment processes including DBS checks were in place.
· Staff were kind, compassionate and formed strong relationships with people they supported.
· People received individualised, person-centred care responsive to their needs.
· Staff communicated well and supported people using their preferred method of communication, with easy-read information available.
Quality-Statement breakdown (23)
safe: Assessing risk, safety monitoring and management. Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Using medicines safelyGood
safe: Learning lessons when things go wrongGood
effective: Working within the principles of the MCA / DoLSRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; supporting people to live healthier lives, access healthcareGood
effective: Adapting service, design, decoration to meet people's needsGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships; follow interests and activitiesGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood