CQC report explained · a residential care home
What the CQC found at Hen Cloud House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People's risks were not always assessed or managed safely. Inspectors found problems with medicine storage, administration and records, although people were protected from abuse and infection control arrangements were considered satisfactory.
- Effective?
- Requires improvement
- Some mental capacity and consent records were missing or unclear. Care plans were not always reviewed or accurate, and some staff said their induction and training were not enough.
- Caring?
- Requires improvement
- Staff showed kindness and respected people's privacy and dignity. However, records and training did not always support consistently person-centred care.
- Responsive?
- Requires improvement
- Care plans and end of life plans were not always complete or personalised. People did not feel there were enough meaningful activities, and some people and relatives did not know how to complain.
- Well-led?
- Requires improvement
- There was no registered manager and leadership had been inconsistent. Audits, records and other quality checks did not reliably identify or address risks.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found caring staff but unsafe medicine practices, weak records and poor oversight.
This was the first inspection since the home was registered. It was unannounced and took place over two days. Inspectors spoke with people, relatives and staff, observed care, and checked care records, staff files, medicine records and management documents.
The home was not always safe or effective. Risks were not always properly assessed, care records were incomplete or inconsistent, and medicines were not always stored, given or recorded safely. Some staff said there were not enough staff and that their training and induction needed improvement.
Inspectors saw kind and caring interactions, and people generally said staff were kind and respected their privacy. However, activities, care planning, complaints information and involvement of people and relatives needed improvement. There was no registered manager, and the systems for checking quality and safety were not effective.
All five areas were rated Requires Improvement: Safe, Effective, Caring, Responsive and Well-led. The report says this means there was limited assurance about safety and an increased risk that people could be harmed. The provider was given warning notices for safe care and treatment and good governance.
Kind interactions
Inspectors observed staff treating people kindly. People generally said staff were caring, respectful and gave them choices.
“We did observe kind and caring interactions between staff and the people they were supporting.” from the report
Safeguarding
Staff had safeguarding training and knew how to respond to abuse concerns. Reported safeguarding concerns had been passed to the appropriate authorities.
“Staff had received safeguarding training and knew how to recognise and respond to concerns of abuse.” from the report
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infection, 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
Purpose-built setting
The home was newly built and designed to meet people's needs. People could personalise their rooms.
“Hen Cloud House is a new service where the premises and environment were purposely built and designed to meet people's needs.” from the report
Medicine safety
seriousMedicines were not always stored, administered or recorded safely. Inspectors found that some discontinued medicines were still being given, and records did not always give staff enough guidance.
“Medicines were not always stored, administered, and recorded in a safe way.” from the report
Risk and care records
seriousSome care plans did not contain enough accurate information about people's needs and risks. This could mean staff did not provide care in the right way.
“Some care planning documentation did not always provide enough information to guide staff to support people in a safe way.” from the report
Consent records
seriousSome mental capacity assessments and legal authorisations were not recorded. The home did not have effective systems to identify possible unlawful restrictions on people's liberty.
“There were no effective systems in place to determine and monitor who was being unlawfully deprived of their liberty and whether appropriate applications needed to be made.” from the report
Staffing and training
needs fixingSome people and staff felt staffing levels were not sufficient. Some staff also said their induction and training for the electronic care planning system needed improvement.
“Some people and staff we spoke with told us they did not feel there were sufficient numbers of staff to enable them to do their jobs effectively.” from the report
Activities and involvement
needs fixingPeople, relatives and staff did not feel there were enough meaningful activities. People and relatives were not always involved in care planning, and the activities coordinator was no longer in post by the second inspection day.
“People, relatives and staff whom we spoke with did not feel there were enough meaningful activities available for people to participate in.” from the report
Weak oversight
seriousAudits and quality checks were not completed consistently. The absence of a registered manager and inconsistent leadership meant important tasks were missed.
“There was no registered manager in place and there had been inconsistent leadership which had led to such tasks being missed.” from the report
- 01What has been done to make sure discontinued medicines are stopped and all medicine records and storage checks are accurate?
- 02How are you making sure each person's risks, health conditions and care preferences are recorded clearly and reviewed on time?
- 03What action has been taken to complete mental capacity assessments and any required DoLS applications?
- 04How many staff are expected on each shift, and what training and induction have new staff completed?
- 05What meaningful activities are now available, and how are people and relatives involved in care planning and complaints?
This was the first unannounced inspection of the newly registered care home and covered all five key questions, including care and the premises, with infection control also checked. This explanation was written from the published report of 2 September 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 Hen Cloud House
Each visit the CQC has published, newest first, back to the day the home was registered.
- September 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2023
Registered with the Care Quality Commission on 2 March 2023.
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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