CQC report explained · a nursing home
What the CQC found at Henford House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2021
Rated Requires Improvement; inspectors found serious medicines-record problems and weaknesses in management oversight.
This was an unannounced focused inspection on 27 April 2021. Inspectors looked only at whether the home was safe and well-led. They spoke with staff and managers, reviewed care, medicines and management records, and received feedback from relatives and a staff member.
The main safety problem was medicines. Three people had not been supported to take prescribed medicines in the eight days before the inspection. Other medicine records were incomplete, so it was not possible to tell whether some people had received their medicines. A diabetes blood sugar meter had also not been checked since October 2020.
The home had enough staff, safeguarding systems and infection control measures. People and relatives said they felt safe and were treated well. However, audits had not found the medicines problems, there was no registered manager, and a legally required notification had not been sent.
The overall rating fell from Good at the previous inspection to Requires Improvement. The CQC asked for an action plan and said it would monitor progress and return for another inspection.
Enough staff
Inspectors found there were enough staff to meet people's needs. People and relatives said staff were usually available when support was needed.
“There were enough staff to meet people's needs.” from the report
Safeguarding
Staff understood how to protect people from harm and knew how to raise concerns. Relatives said they were confident people were safe.
“Staff had a good understanding of what to do to make sure people were protected from harm.” from the report
Infection control
Inspectors were assured that the home had effective arrangements for preventing and managing infection, including the use of protective equipment and visiting arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Family involvement
The home had started residents' and relatives' meetings. People said they were beginning to see improvements after giving feedback.
“The service involved people, their families, friends and others effectively in a meaningful way.” from the report
Medicines were not reliably managed
seriousThree people had not received prescribed medicines, and other records did not show clearly whether medicines had been given. Some liquid medicines were also too old or had no opening date recorded.
“People were not always supported to take the medicines they were prescribed and medicines records had not been fully completed.” from the report
No registered manager
needs fixingThe provider did not have a registered manager, although this was required as a condition of registration. The operations manager intended to apply while the provider recruited a permanent manager.
“The provider did not have a registered manager in post, which is required as a condition of their registration.” from the report
Audits missed problems
needs fixingThe home's checks did not identify the medicines failures or the missed legal notification. The CQC recommended getting guidance on the audit systems and staff training.
“However, the audits had failed to identify the failure to submit the notification when needed or the shortfalls with the medicines management practice we identified.” from the report
- 01What checks now confirm that every prescribed medicine has been given and recorded correctly?
- 02How have you dealt with the missed medicines and the liquid medicines that were out of date or had no opening date?
- 03Has a registered manager now been appointed and registered with the CQC?
- 04What changes have been made to audits so that medicine problems and legally required notifications are identified promptly?
- 05How are you checking the equipment used to manage diabetes, including the blood sugar meter mentioned in the report?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 11 June 2021 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, October 2020
Rated Good; inspectors found improved consent practice, effective care and strong management, but this was a focused inspection and not all areas were rated.
Inspectors visited on 23 September 2020. They reviewed five people's care plans and records, observed care, and spoke with staff and managers. They also checked infection prevention and control measures during the COVID-19 pandemic.
The home was rated Good overall. Effective and well-led were rated Good. Inspectors found detailed assessments, care plans and health records, suitable staff training, and systems for checking and improving quality.
The last inspection had rated the home Requires Improvement because it breached the consent regulation. Inspectors found that improvements had been made and the breach had been resolved. Safe was inspected for infection control but not rated, and this visit did not review Caring or Responsive.
Consent and choice
Mental capacity assessments were detailed. Best-interest decisions involved relatives and professionals where people could not make particular decisions themselves.
“Mental capacity assessments were detailed and clearly evidenced how people had been supported to be involved in decisions.” from the report
Health and nutrition
Care plans recorded health needs, nutrition and hydration needs. People could access health professionals, and those at risk of malnutrition or dehydration were monitored.
“People were supported to have enough to eat and drink, and positive feedback had been received about the food offered at the home.” from the report
Staff training
Staff received induction, mandatory training and dementia training. Managers checked training completion and addressed gaps through supervision.
“There was a thorough managerial oversight of staff training completion.” from the report
Management and culture
The home had regular meetings, audits and action plans. Inspectors observed kind interactions and found that people, relatives and staff were asked for feedback.
“There was a positive and person-centred culture in the home.” from the report
Inspectors raised no specific concerns in this report.
- 01How have you kept the improvements in mental capacity assessments and consent practice since this inspection?
- 02How do you check that staff training remains up to date, and how are any gaps dealt with?
- 03What infection prevention and control arrangements are currently in place for visitors, admissions, PPE and outbreak management?
- 04What actions have resulted from recent audits of care plans, medicines, nutrition, falls and the environment?
- 05How do you involve residents and relatives in decisions and act on their feedback?
This was a focused inspection of Effective and Well-led, with infection prevention and control checked under Safe; ratings for areas not reviewed were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 16 October 2020 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 Henford House
5 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- June 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2020Goodup from Requires improvementSafe: Inspected but not ratedWell-led: Good
- May 2019Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 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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