CQC report explained · a residential care home
What the CQC found at Hengoed Park
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicine records and stock counts were not always accurate, including for controlled drugs. Inspectors also found some environmental and recording risks, although there were enough staff and most people said they felt safe.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried over.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried over.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried over.
- Well-led?
- Requires improvement
- Management checks did not reliably identify problems with medicines, records, recruitment or staff training. The provider also failed to notify CQC about all reportable incidents.
What inspectors found, March 2024
Rated Requires Improvement; inspectors found medicine safety and management oversight were not reliable.
Inspectors visited the home without advance notice on 16, 18 and 30 January 2024. They spoke with 12 people living there, three visitors and 15 staff. They also checked care plans, medicine records, recruitment files and management records.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Medicines were not always properly accounted for, some environmental risks remained, and records and quality checks did not reliably identify problems.
There were also positive findings. Staffing levels were enough during the inspection, people generally said they felt safe, and staff usually respected people's choices. The manager acted on some issues during the inspection, including putting catheter care plans in place and displaying the rating on the website.
This was a focused inspection of Safe and Well-led only. The other question ratings were carried over from the previous inspection, which was published on 2 February 2019 and rated the service Good.
Enough staff
Inspectors saw enough staff to support people safely during the inspection. No one was seen waiting for support.
“The provider ensured there were sufficient numbers of staff to safely support people.” from the report
Safety plans
People's main safety risks were identified and plans told staff how to support them. Support plans were also in place for people who could become distressed.
“People's care records provided staff with information on how to support people safely.” from the report
Respect for choices
People said they could make decisions about daily life, and inspectors saw staff respecting those choices.
“People told us they could make their own decisions about daily living tasks and activities, and we saw staff respected people's choices.” from the report
Medicine records and stock
seriousMedicine balances did not always match the records. Inspectors also found two loose, unlabelled controlled drugs, and some administration records lacked staff signatures.
“Medicines were not always correctly accounted for.” from the report
Management checks
seriousThe provider's checks had not found several important problems. Managers also delayed checking medicine stock after inspectors raised concerns.
“The provider's governance systems were not always effective as they had failed to identify the shortfalls we found at this inspection.” from the report
Reportable incidents
seriousThe home did not notify CQC about some safeguarding concerns and authorised Deprivation of Liberty Safeguards applications as required.
“The registered manager had failed to notify us of these.” from the report
Environmental risks
needs fixingInspectors found a fire door propped open, unsecured wardrobes and equipment stored under the main staircase. Refurbishment work had started, but risks remained.
“On each day of inspection, we found equipment stored under this staircase.” from the report
People's views and engagement
needs fixingRecords did not show people's expectations and care goals clearly. Feedback was mixed, with some people saying they were bored or did not talk with staff about their goals.
“Two people told us staff did not talk with them about what their expectations were for their care and goals.” from the report
- 01What checks are now in place to make sure medicine balances, administration signatures and controlled drugs are correct?
- 02How are you checking that all safeguarding concerns and authorised Deprivation of Liberty Safeguards applications are notified to CQC?
- 03What has been done to secure wardrobes, keep the fire door closed and stop equipment being stored under the main staircase?
- 04How are staff training records being checked so they accurately show who has completed required training?
- 05How will you record people's care goals, expectations and views about life at the home?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried over from the previous inspection in 2019. This explanation was written from the published report of 14 March 2024 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, February 2019
Hengoed Park was rated Good; inspectors found safe, caring support, with ongoing maintenance needed for the older building.
The inspection was unannounced and took place on 11 January 2019. Inspectors spoke with seven people living in the home, staff and social care professionals. They observed daily care and checked care records, medicines, recruitment, training, communal areas, bedrooms and outside spaces.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that staff knew people well, supported their independence and understood their mental health needs. Medicines, staffing, safeguarding and care planning were managed safely.
The home had been rated Good at the previous inspection. Inspectors found that this rating continued to be supported and found no serious risks or concerns from the inspection or ongoing monitoring.
Consistent staffing
The home had a committed staff team and did not use agency staff. This meant people were supported by staff who knew them well.
“We saw that the staff covered the rotas and agency staff were never used so the people living in the home were always supported by staff who knew them well.” from the report
Kind and respectful care
Inspectors saw staff offering reassurance and responding patiently to people who were anxious. People said staff respected their dignity and listened to them.
“The staff member remained patient, caring and kind. The person was consistently offered reassurance.” from the report
Personalised care planning
Care plans described people's needs, routines, preferences and risks in detail. People were given opportunities to be involved in planning their care.
“The care plan files we looked at were person-centred, very detailed and informative, regularly reviewed and reflected the needs of the people living at the service.” from the report
Safe medicines management
Only trained staff administered medicines and their competence was checked regularly. Medicines were stored safely.
“Staff competency was checked regularly and only trained staff could administer medication.” from the report
Older building and tired décor
minorInspectors found that the building was old and some décor looked tired. Maintenance and refurbishment were ongoing, so families may want to ask what work is planned and when it will be completed.
“The building was old and the décor looked tired in some areas.” from the report
- 01What maintenance and refurbishment work is still planned for the older parts of the building?
- 02How would you support my relative's particular mental health, health and dietary needs?
- 03How would my relative be involved in creating and reviewing their care plan?
- 04What activities, education, work or independent living opportunities would be available to my relative?
- 05Who would provide senior support outside the manager's usual working hours?
This was an unannounced inspection covering all five key questions, including the care provided and the premises; all five ratings remained Good. This explanation was written from the published report of 2 February 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 Hengoed Park
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- March 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2019Goodstayed GoodSafe: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 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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