CQC report explained · a residential care home
What the CQC found at Havendene Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Medicines, risks, staffing and infection control had improved, although inspectors recommended fuller accident records and a better interview process.
- Effective?
- Good
- People received food, fluids, healthcare support and staff training suited to their needs. Some care records and training records were still being reviewed.
- Caring?
- Good
- This question was not inspected during this visit. The previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this visit. The previous rating was carried forward.
- Well-led?
- Good
- Management oversight, audits and staff support had improved. Some actions were not always signed off, and the provider was still working through its improvement plan.
What inspectors found, August 2023
Rated Good; inspectors found safer systems and kind care, but some records, recruitment processes and activities still needed improvement.
This was an unannounced focused inspection on 06 July 2023 and 11 July 2023. One inspector, an Expert by Experience and a regulatory coordinator carried out the inspection. They met everyone living at the home, spoke with eight relatives or friends and contacted staff and other professionals.
Inspectors found enough trained staff, safe medicines management, improved infection control and a cleaner environment. People felt safe, enjoyed the food and were supported to make choices. Care records and risk assessments were being rewritten, and the provider had an action plan for remaining work.
The overall rating improved from Requires Improvement to Good. The inspection covered Safe, Effective and Well-led. Caring and Responsive were not inspected, so their previous ratings were carried forward.
People felt safe
People and relatives told inspectors they felt safe and found staff approachable. Safeguarding systems were in place and concerns had been acted on appropriately.
“People felt safe. Medicines were well managed. The premises had undergone an extensive programme of improvements and decorating was now to be completed.” from the report
Medicines were managed well
A clean, dedicated medicine room was in use. People received medicines on time and unused medicines were returned appropriately.
“People received their medicines in a timely manner. One person said, "They are very good, no problems with the tablets.” from the report
Enough staff and support
Inspectors found enough staff on duty. Staff had induction, training, supervision and support, and morale had improved.
“There were enough staff on duty to meet people's needs. One person said, "I think there's enough staff.” from the report
Food and choice
People were offered enough food and drink, with choices that reflected personal preferences and dietary needs. People told inspectors they enjoyed the meals.
“A choice of meals was available, which considered any personal preferences, including for example if people were vegetarian or disliked certain foods.” from the report
Major improvements
The home had undergone substantial refurbishment, including new windows, a kitchen, fire doors and flooring. The provider had an action plan for further work.
“The home had undergone recent extensive refurbishment. This included replacement windows, new kitchen, fire doors and flooring throughout the home.” from the report
Recruitment records
needs fixingInterview questions and interview records were not strong enough for inspectors to confirm that recruitment was consistently fair and thorough. The provider was recommended to improve this process.
“Interview questions and recordings of interviews were not robust. This meant we could not confirm fair and best practice recruitment procedures were in place.” from the report
Accident records
needs fixingSome accident and incident records did not fully show what action had been taken or what had been learned. Inspectors recommended completing these records fully.
“Although action was taken, some accident records were not fully completed to show those actions or lessons learnt.” from the report
Activities
needs fixingActivities were available, but some relatives thought they could be better. Inspectors recommended reviewing activities so they meet everyone's needs.
“Activities took place, but we received comments from some relatives to say this could be better.” from the report
Work still to finish
minorSome decorating remained after the refurbishment, and an infection control dispenser needed moving. These actions were being dealt with by the provider.
“There was some decorating to take place after the recent work in the home had been completed.” from the report
Records and training under review
minorCare plans were being rewritten and there were a few gaps in training, although most training was complete and an action plan was in place.
“There had been no impact, but there were a few gap in training. However, the vast majority was completed and up to date.” from the report
- 01What has been done to improve interview questions and keep clear records of interview answers?
- 02How are accident and incident records now checked to make sure actions and lessons learned are recorded?
- 03What activities are available for people with different interests and needs?
- 04When will all care plans and risk assessments be fully reviewed and updated?
- 05What remains to be done on the decoration, infection control equipment and staff training gaps?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 12 August 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, January 2023
Havendene Residential Home was rated Requires Improvement; inspectors found kind care but serious weaknesses in medicines, safety, cleanliness, records and management.
This was an unannounced focused inspection on 8, 14 and 15 December 2022. Inspectors looked at Safe, Effective and Well-led because concerns had been raised about care and the environment. They spoke with 15 people, 14 relatives and staff, and reviewed care, medicines, recruitment and management records.
The home was not always safe. Medicines were not managed properly, some records were incomplete, fire safety work had been delayed and many areas were dirty. The building also needed repairs and refurbishment. Records, risk assessments and management checks were not reliable enough.
There were also positive findings. People and relatives said they felt safe, and described staff as kind and caring. There were enough staff, people generally enjoyed the food, staff used protective equipment properly and the home worked with health and care professionals. The overall rating fell from Good at the previous inspection to Requires Improvement.
Kind and caring staff
People and relatives spoke positively about the staff's caring nature. Inspectors observed positive, person-centred interactions.
“Positive person-centred interaction took place throughout the inspection between people and the staff team.” from the report
People felt safe
People and relatives said they felt safe and believed people's care needs were being met.
“People told us they felt safe. Relatives confirmed those views.” from the report
Safe recruitment
The home carried out key recruitment checks, including criminal record checks and references.
“Staff were recruited safely. This included checks from the Disclosure and Barring Service (DBS) and obtaining references.” from the report
Protective equipment
Staff used protective equipment appropriately, and visitors were encouraged to do the same.
“Staff wore PPE appropriately and visitors were encouraged to do the same.” from the report
Links with professionals
The home worked with health and care professionals to support people. A professional said the home was responding to advice and things were improving.
“The service worked with other organisations and professionals such as the local authority, GP's and district nurse teams” from the report
Medicines were not managed safely
seriousThe medicines room was cluttered and also used as an office. Administration records had gaps, controlled drugs were not stored properly and staff competency checks were not up to date.
“Medicines were not managed safely. The medicines room was not fit for purpose, including being used as an office.” from the report
Fire safety and building repairs
seriousFire doors identified as unsuitable had not been replaced in a timely way. Flooring, walls, furniture, gardens and the kitchen also needed work.
“There had been a delay in fitting of new fire doors as current doors had been identified by the fire service as inappropriate earlier in the year.” from the report
Poor cleanliness and infection control
seriousMany areas were dirty or dusty, some furniture and equipment was not clean, and cleaning records were incomplete. Inspectors also found bare-below-the-elbow rules were not always followed.
“The home was dirty and dusty in many areas, including individual bedrooms, communal bathrooms, toilets and lounge/dining areas.” from the report
Incomplete care and risk records
needs fixingSome risk assessments were missing, and care plans had not always been updated after changes in people's needs. Some records were not person-centred.
“People's needs, and choices were assessed and written in their care plans. However, when changes or issues relating to people's care had occurred or been reported; records had not always been updated or reviewed.” from the report
Weak management oversight
needs fixingAudits and checks did not consistently identify or resolve problems. The report also says improvement had been limited and slow since the previous inspection.
“Quality checks and oversight by the provider were not robust. Audits and monitoring checks had not always been effective.” from the report
Limited meal choice
needs fixingPeople generally enjoyed the food, but they were not always offered a choice and were often offered only one type of meal. Dietary and weight records were also not always complete.
“People were not always offered choice at meal times and people confirmed they were often only offered one type of meal.” from the report
- 01What has been done to make the medicines room suitable, secure controlled drugs and ensure every medicine administration is recorded?
- 02Have the replacement fire doors been fitted, and what is the timetable for completing the remaining fire safety work?
- 03How are bedrooms, bathrooms, shared areas, furniture and equipment now cleaned and checked?
- 04How do you make sure care plans, risk assessments, nutrition records and dietary information are complete and updated after changes?
- 05What additional staff or resources are now in place to complete the repairs and improvement work safely?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used. This explanation was written from the published report of 26 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.
Every inspection of Havendene Residential Home
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- August 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2023Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- December 2021GoodSafe: Inspected but not ratedWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- August 2020Requires improvementstayed Requires improvementSafe: GoodEffective: GoodWell-led: Requires improvement
- January 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018
Registered with the Care Quality Commission on 12 March 2018.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
23 live-in carers within about an hour of Northumberland
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,190 a week. 20 can care for a couple. 11 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.