Updated 20 April 2022
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
This inspection team consisted of an inspector, a specialist professional advisor in nursing and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The Expert by Experience made telephone calls on the 28 March 2022, off site, to obtain feedback from people who used the service and their relatives.
Service and service type
Henley House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Henley House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
The provider had recently recruited a manager who at the time of the inspection had been in post a month and was applying to be registered with the Care Quality Commission.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed our systems and information we held about the service. This included the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with nine people who used the service and two relatives about their experience of the care provided. We spoke with the manager, head of care and compliance, business support manager, two senior care staff, four care workers, an activities’ lead, two housekeeping staff, an administrator and the head of maintenance.
We reviewed a range of records which included risk assessments and care records for six people, medication records for 10 people and two staff files. We also viewed complaints, accident and incident records and management monitoring and oversight records.
On the 28 March 2022 the Expert by Experience spoke with five people who lived at the home and four relatives.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with three members of staff and received electronic feedback via email from six members of staff. We also received email feedback from the local authority commissioning team