CQC report explained · a nursing home
What the CQC found at Henwick Grange
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2022
Henwick Grange was rated Good; inspectors found safer, kinder and better-managed care after earlier improvements.
This was an unannounced focused inspection on 26 September 2022. Inspectors looked at Safe, Effective, Caring and Well-led. They spoke with people, relatives, staff and a healthcare professional, observed care and checked care, medicine, recruitment and management records.
Inspectors found that medicines and risks were managed safely. Staff were trained and safely recruited. People received suitable food and access to healthcare. Staff were kind and respectful, and people and relatives were involved in care decisions.
The home had improved since the previous inspection. Its systems for checking quality were stronger, and it was no longer in breach of regulations 12 and 17. The overall rating changed from Requires Improvement to Good. Responsive was not inspected during this visit, so the overall rating included an earlier rating for that area.
Safer medicines and risk checks
Medicine records were accurate, including checks for patches. Care plans gave staff clear guidance about risks such as skin damage, and incidents were reviewed for learning.
“Medicines were managed safely and recorded accurately.” from the report
Suitable food and healthcare
Meals were adapted to people's needs and preferences. People had choices, snacks and drinks, and could access a range of health professionals.
“People were given choices of what they wanted to eat and were provided with snacks and drinks throughout the day.” from the report
Kind and respectful staff
Inspectors saw positive interactions. People were supported to choose where to spend time and where to eat, and relatives were kept informed about changes.
“Staff were observed and heard to be kind, respectful and patient when interacting with people.” from the report
Improved management
The home had developed its quality checks and acted on areas needing improvement. Staff said communication and support had improved.
“The registered manager had developed their quality assurance systems since the last inspection.” from the report
Family involvement
People and relatives were involved in care planning and could give feedback through meetings and surveys. This feedback was used to make changes.
“People and relative's feedback were sought through regular conversations, residents' meetings and feedback surveys to drive through improvements.” from the report
Shared moving equipment
minorOn one occasion, a sling was shared between two people. Inspectors discussed this with the manager, who put measures in place to prevent it happening again.
“there was one occasion where a sling had been shared between two people.” from the report
Some decoration still needed
minorThe home was clean overall, but some walls needed decorating. This had already been identified and work was being progressed.
“The home environment presented as clean. However, there were some areas which required attention such as walls that needed decorating.” from the report
- 01What measures are now in place to make sure slings are not shared between people?
- 02When will the decorating work identified by inspectors be completed?
- 03How are medicine patch checks and site rotation recorded and reviewed?
- 04How will you continue to monitor the improvements made after the previous inspection?
- 05What activities and support are available to meet my relative's individual preferences and daily choices?
This was an unannounced focused inspection of Safe, Effective, Caring and Well-led, including infection prevention and control under Safe; Responsive was not inspected and its previous rating was used in the overall rating. This explanation was written from the published report of 16 November 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, April 2021
Rated Requires Improvement; inspectors found risks in medicines and pressure-area care, with weak management oversight.
This was an unannounced focused inspection on 10 February 2021. Inspectors looked only at Safe and Well-led, including infection prevention and control. They spoke with people, relatives, staff and managers, and checked care, medicines, staffing and management records.
The home was not always safe. Medicines records were incomplete, and staff did not always follow instructions for repositioning people at risk of skin damage. One person was not repositioned for up to 17 hours, despite advice to reposition every two hours.
Management systems did not reliably identify or correct these problems. The home had no registered manager and had received Requires Improvement at three consecutive inspections. There were some positive findings, including safe staff recruitment, enough staff to respond to calls, and infection control arrangements that inspectors found reassuring.
The overall rating was Requires Improvement. Safe was rated Requires Improvement, down from Good at the previous inspection. Well-led remained Requires Improvement. CQC identified breaches of Regulations 12 and 17 and said it would monitor the home and return to check progress.
Staff recruitment
The provider carried out checks before employing staff to make sure they were suitable to work with people at the home.
“The provider followed safe recruitment procedures to ensure prospective staff were suitable to work with the people living at the home.” from the report
Staff availability
Inspectors saw enough staff to respond to requests for help and call bells without unreasonable delay.
“We saw there were enough staff to respond to requests for assistance and call-bells without unreasonable delay.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infections, including use of protective equipment and testing.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Incident learning
Accidents and incidents were recorded, reviewed and discussed with staff when needed.
“Learning from incidents was reviewed and if necessary, discussed at staff team meetings.” from the report
Working with health professionals
The management involved relevant health professionals to support people's care and had developed good working relationships with them.
“The management had involved GP's, tissue viability nurse and speech and language therapists to support people's care and developed good working relationships.” from the report
Medicines records
seriousThere were no daily checks showing whether some medicine patches remained in place, and some medicines given when needed did not have the reason or outcome recorded.
“Medicines were not always managed safely and recorded accurately.” from the report
Pressure-area care
seriousStaff did not always follow specialist instructions about repositioning. Care records showed one person was not repositioned for up to 17 hours, creating a risk of harm.
“Staff had not always followed the instructions of the tissue viability nurse.” from the report
Weak oversight
seriousThe home's checks and governance systems did not identify or correct important care problems. CQC said the provider had failed to make and sustain improvements over three inspections.
“The provider failed to operate effective systems and processes to assess, monitor and improve the quality and safety of the service.” from the report
No registered manager
needs fixingThere was no registered manager in post, and the report says this had been the case since July 2019. Relatives gave mixed feedback about communication and management turnover.
“There had not been a registered manager in post since July 2019.” from the report
Communication with relatives
needs fixingSome relatives reported difficulties keeping in touch during the COVID-19 pandemic, although another relative said they had a good relationship with staff.
“We received mixed responses from relatives about communication and their involvement with the home.” from the report
- 01What has changed to make sure every medicine patch is checked, changed and recorded correctly?
- 02How do you now make sure people at risk of pressure damage are repositioned as instructed, and how do you audit this?
- 03Who is currently responsible for the home while there is no registered manager, and when do you expect a registered manager to be in post?
- 04What action has been taken in response to the Regulation 12 and Regulation 17 breaches?
- 05How do you check that the action plan has led to lasting improvements rather than temporary changes?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not assessed and no new ratings were given for them. This explanation was written from the published report of 16 April 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.
Every inspection of Henwick Grange
6 rated inspections over 7 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2020Requires improvementstayed Requires improvementSafe: GoodWell-led: Requires improvement
- January 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementWell-led: Requires improvement
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 1 November 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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