CQC report explained · a residential care home
What the CQC found at Havengore House Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2022
Rated Good after improvements; inspectors found safe, personalised care and better complaints handling, but this was a focused inspection.
The home provides personal and nursing care for up to 22 older people, including some people living with dementia. There were 19 people living there when inspectors visited.
This was an unannounced focused inspection on 19 January 2022. One inspector spoke with people, relatives, staff and managers, observed care, and checked care records, staff files and quality checks.
Inspectors rated Safe, Responsive and Well-led as Good. They found suitable staffing, safe medicines arrangements, infection control, personalised care, activities, and improved complaints handling.
The home was previously rated Requires Improvement in 2019 because complaints were not handled properly. Inspectors found the improvements had been made and the home was no longer in breach. The overall rating changed to Good, but Effective and Caring were not inspected at this visit.
Staffing and safety
There were enough staff to meet people's needs. Inspectors found that staff responded promptly and understood people's individual risks.
“The deployment of staff was appropriate and there were enough staff to meet people's needs.” from the report
Safe medicines
Medicine records checked by inspectors were in good order. Staff were trained and audits showed high compliance, with action taken when shortfalls were found.
“These were in good order, provided an account of medicines used and demonstrated people were given their medicines as specified by the prescriber.” from the report
Personalised care
Care plans covered individual needs, likes and preferences. They were reviewed when people's needs changed.
“People received good personalised care and support that was responsive to their needs.” from the report
Activities and family contact
People could choose how to spend their time and were offered social and leisure activities. Arrangements also supported family visits during the pandemic.
“Suitable arrangements were in place to ensure people had the opportunity to take part in leisure and social activities of their choice and interest.” from the report
Improved complaints handling
The home had improved how it recorded, investigated and responded to complaints since the previous inspection. Inspectors found investigations were open and included lessons learned.
“Each complaint had been responded to and investigated in an open and transparent way.” from the report
Management and culture
Inspectors found a positive, open culture focused on people's individual needs. Quality checks were used to monitor and improve the service.
“The service had a positive culture which ensured the care provided for people using the service was person-centred, open, inclusive and focused on people's individual care and support needs.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you currently check that care is effective and that people's health needs are being met?
- 02How do you make sure staff provide caring support and protect people's dignity in day-to-day practice?
- 03How are care plans reviewed when a person's needs, preferences or communication needs change?
- 04What activities are available for someone with my relative's interests and abilities?
- 05How can we raise a complaint, and how will we be told what action was taken and what was learned?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their ratings were carried over from the previous inspection. This explanation was written from the published report of 17 February 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, May 2019
Rated Requires Improvement; inspectors found kind and effective care, but identified safety, complaints, end-of-life planning and management weaknesses.
This was an unannounced inspection over two days. One inspector observed care, spoke with people, relatives and staff, and reviewed care records, medicines, recruitment files, training records, complaints and quality checks.
People generally said they felt safe and were treated kindly. Staff knew people's needs, there were enough staff, medicines were managed safely, and people received suitable food, drink and healthcare. The effective and caring areas were rated Good.
The inspection also found unsafe moving and handling, gaps in recruitment records, weak complaint investigations and missing information about some people's end-of-life wishes and symptom management. The home's quality checks had not found these problems. Safe, responsive and well-led were rated Requires Improvement.
This was the first inspection since the service was registered with a new provider. The overall rating means the home was not consistently meeting the expected standard and needed to make improvements.
Kind, respectful care
People and relatives spoke positively about staff. Inspectors saw good relationships and found that privacy, dignity and independence were supported.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Enough staff
Inspectors found enough staff to meet people's needs, and staff responded to care needs in good time.
“The deployment of staff was appropriate and there were enough staff available to meet people's needs.” from the report
Good food and healthcare
People spoke positively about meals and could choose where to eat. The home worked with other organisations and people could access healthcare when needed.
“People had access to food and drink throughout the day and the overall dining experience for people was positive.” from the report
Unsafe moving and handling
seriousInspectors saw staff move two people in an unsafe way that could cause pain or injury. The manager discussed this with the staff involved during the inspection.
“This technique is unsafe, can hurt and cause injury because the person's armpits and shoulders have too much pressure on them.” from the report
Recruitment checks
needs fixingSome recruitment records did not show that checks had been completed properly before employment. The manager later provided explanations and said records had been corrected or filed elsewhere.
“Improvements were required to make sure staff employed had been recruited safely to ensure they were suitable to support vulnerable people.” from the report
Complaints were not fully investigated
seriousOne complaint was not fully investigated and records did not clearly support the conclusions. The complainant said they were unhappy, but this was not followed up.
“Effective arrangements were not in place to investigate, record and respond to complaints.” from the report
End-of-life information
needs fixingThe report found no evidence that people were receiving inappropriate end-of-life care, but records did not explain how symptoms and pain should be managed or record people's wishes. A new care plan document was created during the inspection.
“No information was recorded relating to how the person's end of life care symptoms and pain management arrangements were to be managed” from the report
Quality checks missed problems
needs fixingThe home's monitoring systems did not identify the issues found by inspectors. This meant managers did not have effective oversight of all areas of care.
“These arrangements had not identified the issues found during our inspection.” from the report
- 01What training and checks now ensure staff use safe moving and handling techniques every time?
- 02How do you make sure identity checks and references are completed and recorded before staff start work?
- 03How are complaints now investigated, recorded, answered and followed up if the complainant remains unhappy?
- 04How do you record each person's end-of-life wishes, symptoms and pain management arrangements?
- 05What quality checks now test whether these improvements are working?
This was an unannounced planned inspection that considered all five CQC questions and looked at both the accommodation and the care provided. This explanation was written from the published report of 8 May 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 Havengore House Residential Care Home
2 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- February 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Havengore House Residential Care Home →
- May 2019Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Havengore House Residential Care Home →
- March 2018
Registered with the Care Quality Commission on 7 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.
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