CQC report explained · a nursing home
What the CQC found at Hendra Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected by safeguarding, risk assessment and medicine systems. However, inspectors found obstructions near fire exits, poorly stored aprons and some medicine entries without the required second signature.
- Effective?
- Good
- This key question was not rated as part of this inspection.
- Caring?
- Good
- This key question was not rated as part of this inspection.
- Responsive?
- Good
- This key question was not rated as part of this inspection.
- Well-led?
- Good
- Managers had effective oversight and staff and most relatives said the home was well run and approachable. One relative raised concerns about communication and meals.
What inspectors found, February 2023
Hendra Court was rated Good; inspectors found safe, caring support, but identified fire safety, infection control and food concerns.
This was an unannounced inspection on 4 January 2023. One inspector and an Expert by Experience spoke with staff, relatives and people living at the home. They also reviewed care plans, medicine records, training records and management information.
The home was rated Good overall. Safe and Well-led were both rated Good, and these ratings stayed the same as at the previous inspection in July 2018. Inspectors found enough staff to meet people's needs at the time, although a COVID-19 outbreak had put staffing under pressure and there were vacant posts.
Inspectors found effective safeguarding, risk management and medicine systems. They also found fire exits and landings obstructed, aprons stored poorly and some medicines records without the required second signature. These issues were dealt with during the inspection, and recommendations were made about fire and infection risk checks.
Safeguarding
Inspectors found effective systems to protect people from abuse. Staff knew what action to take, and concerns had been reported appropriately.
“The provider had effective safeguarding systems in place and staff knew what actions to take to help ensure people were protected from harm or abuse.” from the report
Staffing and recruitment
There were enough staff to meet people's needs during the inspection. Recruitment checks included references and DBS checks, although vacant posts remained.
“There were enough staff to meet people's needs and ensure their safety.” from the report
Management oversight
The manager and clinical lead understood people's needs and used audits and quality checks to improve the service.
“The registered manager and the clinical lead had effective oversight of the service and were very knowledgeable about the needs of people they supported.” from the report
Activities and relationships
Relatives described regular activities and said people were not simply left sitting or sleeping. Staff were described as caring and approachable.
“There is always some activity or board game going on, it was one of the things that helped us decide on Hendra Court.” from the report
Fire exits and clutter
seriousInspectors found items blocking some fire exits and clutter on landings. This could have made it harder for people to leave safely in an emergency.
“During our tour of the service we identified some obstruction of fire exits with items such as a broken TV, a box of books, ladders and wheelchairs, which potentially would impede the safe exit of people in an emergency.” from the report
Infection control storage
needs fixingStaff coats and bags were stored near food and crockery. Single-use aprons were also left on handrails and some had fallen on the floor. These issues were addressed during the inspection.
“Staff coats and bags were found where food and crockery were stored. This was a potential infection risk, especially as the service was in a COVID-19 outbreak at the time of this inspection.” from the report
Medicine records
needs fixingSome handwritten medicine entries had not been signed by two staff as required by the home's policy. This was corrected during the inspection.
“However, we found some handwritten entries had not been signed by two staff, in accordance with the policy.” from the report
Staffing pressure
needs fixingA COVID-19 outbreak caused short-notice staff sickness and staffing levels sometimes fell below the planned level. The home covered most shifts with regular agency staff, but vacant posts remained.
“There had been times when staffing levels had dropped below what was planned.” from the report
- 01What checks are now made to ensure fire exits and landings stay clear?
- 02How are food temperatures and reports of soggy or cold meals being monitored?
- 03How do you ensure all medicine entries receive the required second staff signature?
- 04How are infection risks from storing aprons, coats and bags being prevented?
- 05How many staff vacancies remain, and how would staffing be maintained during sickness or another outbreak?
This inspection focused on Safe, including infection prevention and control, and Well-led; the other key questions were not rated and the overall rating carried over as Good from 2018. This explanation was written from the published report of 1 February 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, July 2018
Hendra Court was rated Good across all five areas; inspectors found safe, kind and personalised care, with major premises improvements completed.
This was an unannounced comprehensive inspection on 6 July 2018. Inspectors observed care, looked around the home and reviewed care records, staff files, training records, rotas and other documents. They spoke with people living there, relatives, staff and a visiting healthcare professional.
The home was rated Good overall and Good for Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitably trained staff, safe medicines arrangements, personalised care plans and kind interactions. People and relatives said they were happy with the care and felt safe.
The inspection also checked improvements recommended in June 2017. Records of care monitoring had improved. Major building work had been completed, including changes intended to reduce isolation and improve access to shared areas and gardens.
Safe medicines
Medicines were stored and given safely. Records were complete, including arrangements for medicines given when needed.
“There were safe arrangements in place for the administration of medicines. People were supported to take their medicines at the right time by staff who had been appropriately trained.” from the report
Improved surroundings
Major work to improve the building had been completed. New layouts, shared areas and enclosed gardens helped people access communal and outdoor spaces more easily.
“At this inspection we found all the major work had been completed.” from the report
Personalised care
Care plans included people's needs, preferences and routines. Staff could explain how individuals wanted to be supported.
“Care plans were personalised to the individual and gave clear details about each person's specific needs and how they liked to be supported.” from the report
Kind staff
Inspectors saw warm and respectful interactions. People appeared comfortable with staff and were willing to ask them for help.
“We saw many examples of positive interactions between staff and people during the day.” from the report
Strong oversight
Managers were visible and approachable. Regular audits and meetings were used to identify and address improvements.
“There were effective quality assurance systems in place to make sure that any areas for improvement were identified and addressed.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you now check that repositioning, skin checks and food and fluid monitoring records are completed consistently?
- 02How many care and nursing staff are usually on duty for each area of the home, and how is this changed when people's needs increase?
- 03How do you make sure the completed building changes continue to prevent people from becoming isolated?
- 04Which activities are currently available, and how do you match them to each person's interests and choices?
- 05How are people's decisions reviewed when they cannot make particular decisions themselves, including any restrictions on their freedom?
This was a comprehensive inspection covering all five CQC questions, the care provided and the premises. This explanation was written from the published report of 21 July 2018 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 Hendra Court
3 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2017Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2016
Registered with the Care Quality Commission on 22 December 2016.
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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