CQC report explained · a residential care home
What the CQC found at Haylands Residential Home for Gentlemen
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always administered or recorded correctly. Care plans did not always reflect changing risks, and some accidents and incidents were not formally recorded.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management systems did not consistently keep records up to date or identify problems. The training matrix had several gaps, although staff said they felt supported and there was good morale.
What inspectors found, October 2022
Haylands Residential Home for Gentlemen was rated Requires Improvement; inspectors found medication and management checks were not always reliable.
This was an unannounced focused inspection on 24 and 25 August 2022. One inspector reviewed three care plans, medicines records, health and safety records and two staff files. They also spoke with people living there, relatives and staff.
The home was not always safe. Medicines had been recorded as given when stock records suggested they had not been given. There were no clear instructions for some medicines given when needed. Care plans and records of accidents were also not always kept up to date.
Inspectors found kind and positive relationships between staff and people living there. People were supported to make choices, stay involved and access the community. However, staff training records had several gaps and some management checks did not identify or prevent the problems found.
The overall rating fell from Good at the previous inspection, published on 2 September 2017, to Requires Improvement. Only Safe and Well-led were inspected in this visit. The other ratings carried over from the previous inspection.
Kind staff
People gave positive feedback about staff. Inspectors observed people being supported with mobility and encouraged to be independent.
“the staff are great, I like the way they treat people, if they say they are going to do something, they do it.” from the report
People’s choices
People were supported to have choice and control, take part in decisions and access the local community.
“Staff supported people to access the local community and engage in activities they enjoyed.” from the report
Safeguarding arrangements
The home had safeguarding systems and staff understood how to recognise and report possible abuse. Inspectors found that concerns were responded to appropriately.
“The staff we spoke to had a good understanding of abuse, signs to look for and how to raise concerns.” from the report
Welcoming relatives
Relatives were encouraged to visit and said staff were accommodating. Staff also shared activity updates with relatives online.
“Visitors were supported to visit their friends and family in line with the government guidance.” from the report
Medicines not always safe
seriousThere were occasions when medicine was signed as given but stock records suggested it had not been given. Instructions for some medicines given when needed were missing, and thickener use was not recorded.
“Medicines were not always administered or recorded as given.” from the report
Care plans and risk records
needs fixingCare plans and risk assessments were not consistently updated when people’s needs changed. One care plan did not include information about using thickener.
“Risk assessments and care plans were not consistently updated to reflect people's needs.” from the report
Accident records
needs fixingTwo incidents had not been formally recorded. Monthly reviews did not clearly show what had been learned to reduce the risk of future falls.
“Accidents and incidents were not always recorded at the service.” from the report
Staff training records
needs fixingThe training matrix showed several gaps, including refresher training in safeguarding and the Mental Capacity Act. The manager said the records were inaccurate and the provider was changing training providers.
“The training matrix showed multiple gaps in relation to refresher training in areas such as safeguarding and MCA.” from the report
- 01What changes have been made to ensure every medicine is given and recorded correctly?
- 02How are medicines given when needed now supported by clear instructions for staff?
- 03How do you check that care plans and risk assessments are updated when a person’s needs change?
- 04What has been done to make sure all accidents and incidents are recorded and reviewed for learning?
- 05Which staff training gaps have been completed, particularly safeguarding and Mental Capacity Act refresher training?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 7 October 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, September 2017
Rated Good; inspectors found safe, caring and well-managed support, with some room to improve food, activities and building works.
The inspection was unannounced and took place on 7 August 2017. Inspectors observed care, spoke with 12 people, a relative and staff, and checked care, medicines, safety and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer medicines systems, detailed care plans and kind, respectful support.
This was a clear improvement from the previous inspection in July 2016, which was rated Requires Improvement. The earlier breaches about safe care and treatment and good governance were no longer breaches at this inspection.
Improved medicines safety
Inspectors found that medicines were ordered, stored, administered and disposed of safely. Records checked had no gaps, and refusals were recorded.
“We checked the medication administration records (MAR) and saw that there were no gaps” from the report
Kind and respectful care
Staff knew people well and communicated with them warmly. Personal care was provided privately and people's dignity was respected.
“We saw in all cases people were cared for by staff that were kind, patient and respectful.” from the report
Detailed care planning
Care plans recorded people's routines, preferences and support needs. They were reviewed and updated when people's needs changed.
“Care plans were written in a person-centred way and contained detailed information for staff about their daily routines, preferences and how people wished to be supported.” from the report
Stronger management systems
The home had introduced regular audits, documented staff competency checks and meetings where people, relatives and staff could share views.
“At this inspection we saw that a clear system of audits was in place and governance systems had improved the quality assurance processes at the home.” from the report
Mixed views about food
minorPeople had choices and nutritional needs were monitored, but inspectors received varied opinions about the quality of the food.
“However, we received varied opinions on the quality of food on offer.” from the report
Activities could be stronger
minorActivities were planned and some had taken place, but some people felt there were not enough activities, especially when the activities co-ordinator was away.
“However, some people still felt the activities could be improved even further.” from the report
Building work was unfinished
needs fixingSome actions from fire and electrical checks were still being completed. The stair lift also left a gap that could cause a trip hazard, and further work was planned.
“The registered manager confirmed this would be raised with the owners to ensure the cushion guard was extended further.” from the report
Future wishes still developing
needs fixingSome people's future wishes had been recorded, but the home said this area was still being developed and wanted to discuss these wishes more consistently.
“Discussions with the registered manager confirmed this area was still being developed” from the report
- 01Have all the actions from the June 2017 fire risk assessment and electrical condition report now been completed?
- 02Has the gap beside the replacement stair lift been made safe?
- 03What activities are provided when the activities co-ordinator is away?
- 04How do you respond to people's views about the quality of the food?
- 05How are people's future and end of life wishes discussed and recorded?
This was an unannounced inspection of the overall service, including observations, conversations and records across all five CQC questions. This explanation was written from the published report of 2 September 2017 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 Haylands Residential Home for Gentlemen
3 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Haylands Residential Home for Gentlemen →
- September 2017Goodup from Requires improvementSafe: GoodWell-led: Good
Read what inspectors found at Haylands Residential Home for Gentlemen →
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 4 April 2011.
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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