OSJCT Henlow Court

Updated 21 March 2023

The inspection

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.

Inspection team

The inspection team consisted of 2 inspectors and 2 Experts 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.

Service and service type

OSJCT Henlow Court 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. OSJCT Henlow Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in 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 9 people who used the service and gathered feedback from 2 relatives about their experience of the care provided. We spoke with 7 members of staff including the registered manager, area operations manager, 2 care leaders, a housekeeper, and 2 care staff.

We reviewed a range of records. This included a sample of 4 people's care records, a variety of records relating to the management of the service, including a review of some policies and procedures.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at policy and quality assurance records. We sought feedback from 8 relatives and 2 professionals about their experience of the care provided.

Updated 21 March 2023

About the service

OSJCT Henlow Court is a residential care home providing personal and nursing care to up to 40 people. The service provides support to older people, some of whom have a diagnosis of dementia. At the time of our inspection there were 32 people using the service.

People’s experience of using this service and what we found

On the day of our inspection staff did not consistently follow safe infection prevention and control procedures which placed people at risk of harm.

People's care records were not always robust enough and did not always contain the necessary detail to evidence the care, support and treatment people received.

Whilst there were systems and processes to assess and manage risks to people, they had not been operated effectively and had not identified some of the shortfalls we found in relation to wound management and infection prevention and control.

The provider needed to make improvements to the way they recorded the action they had taken in response to information of concern. We have made a recommendation about the recording of investigations and information of concern.

We received mixed feedback relating to staffing levels at the home. The registered manager told us the measures they had put in place to cover staff absence.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, there was not a clear record to show that consideration had been given to the principles of the MCA when there had been a change in a person’s mental capacity. The registered manager took immediate action to resolve this in response to our feedback.

People were protected against the risks of potential abuse and they told us they felt safe in the home. Staff knew about safeguarding people and told us they felt confident to report any concerns.

People using the service and their relatives were happy with the care they received. They spoke positively about the staff and told us they were treated with kindness and respect.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 8 November 2017).

Why we inspected

We received concerns in relation to wound care. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. You can see what action we have asked the provider to take at the end of this full report.

The provider took action to correct the issues we identified and also put in place systems to minimise any risk to people.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for OSJCT Henlow Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.