Archived: OSJCT Henlow Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence people were protected from abuse and avoidable harm. At the last inspection the key question was rated requires improvement. At this inspection it is rated good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff listened to concerns about safety and investigated and reported safety events.

The service was actively working to improve its oversight of incidents. The provider kept records of accidents and incidents and reviewed monthly to determine any themes and actions needed. The provider had started to implement a new system to improve the effectiveness of incident reporting and analysis, for example in wound care management. The service worked proactively to identify, record and monitor wound care.

The service worked with healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People were accepted into the service safely. The service had positive relationships with health and social care professionals. The service was in regular contact with the local GP surgery and community nurses. Where people needed to move to alternative accommodation, staff worked well with agencies to co-ordinate and facilitate this.

Whilst Mental Capacity assessments and Best Interest decisions for people were routinely completed, these sometimes lacked detail and information. Some Mental Capacity Assessments were missing relevant information and did not demonstrate how people were involved in the process. Specific Mental Capacity assessment and best interest decisions, for example the use of pain patches or anti-psychotic medication, were not always present.

The service made appropriate referrals to the Local Authority when people required a Deprivation of Liberty Safeguards (DoLS) assessment.

The provider shared concerns quickly and appropriately. Staff we spoke with told us they knew how to escalate concerns. People and their relatives told us they felt safe and knew who to talk to if they had any concerns. One person told us “I feel safe because the staff look after me, the majority are lovely. No worries that I’m not safe.” And a relative told us “I feel that now safety protocols in place. They record falls, head injuries, people are observed every hour."

The service did not always work well with people to understand and manage risks.

Risks were assessed but new emerging risks were not always effectively identified or monitored. Some people required more support with eating and drinking than was recorded in their eating and drinking plan. We observed people being supported with their meals by carer’s, one person was being supported to eat in bed, the carer was stood up and leant over them to feed them. The person had a care plan in place due to their weight loss, including a specified amount of fluid the person should aim to drink daily. However, there was no way for staff to know if the care plan requirements had been met as no records were being kept. We were told the provider did not record what people ate and drank unless there was a specific reason to do so. We raised our concerns with the provider; they started to take action during the assessment.

During our assessment we observed one person who cannot make decisions about their care who did not eat their main lunch time meal. We noticed another person cared for in bed who fluid level within their water jug did not change throughout the day. Daily care records did not reflect these observations.

Prior to this assessment we had received concerns regarding wound care management and medicines, on the day of inspection we found the provider had implemented a plan to address issues identified. A senior manager now had oversight of wound care at the service which was helping with improvements. Staff were receiving more support in managing wounds for people and how and when to escalate them.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We found that the environment and equipment were subject to regular safety checks, and all required safety certificates were current and up to date. Staff demonstrated a good awareness of their responsibilities in maintaining a safe environment. They told us they felt supported and confident in managing safety and described how training and guidance were accessible when needed. During the inspection, we identified an issue with how staff would respond to a fire alarm in the laundry area. The provider assured us that all staff, including new starters, were now aware of the correct procedures to follow in the event of a fire.

Environmental and fire risk assessments were in place and up to date. People had personal emergency evacuation plans (PEEPS) in place within a grab bag to ensure people were supported safely in an emergency.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support. The provider had a service improvement plan in place to reach target training levels by 31st July 2025. However, during our assessment, we found several gaps in training. The provider had some training booked in for the near future, but this did not cover all of the gaps identified. Some care staff had not completed training in fluids and nutrition in over 7 years. This is important because people living at the service have a number of conditions such as diabetes and dementia and ongoing wounds that may require additional support with fluid and nutrition.

Rotas we reviewed did not always show a consistent number of staff on duty during the day and night shifts. However, whilst the provider told us they always had sufficient numbers of staff as per their dependency tool to meet people’s needs we received feedback from staff and people’s relatives that there were not enough staff on especially at weekends. One staff member told us “Not enough, we can meet the needs of the residents but there's not enough time to spend with the residents” and another staff member told us “Does depend on the residents we have, at the moment we are managing good because of the kind of residents we have.”

One person told us “‘There are not enough staff and if there aren’t enough staff the stress gets passed on to you. They never take it out on me, I don’t know how they keep their patience sometimes.” And a relative told us “I see lots of staff, in the week. I might not see one-minimal staff at weekends”.

The service had started to implement an appraisal system with staff; but this needed time to fully embed.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service assessed and managed the risk of infection. They detected and controlled the risk and shared concerns with appropriate agencies promptly.
The home appeared clean.

Feedback we received told us people felt the home was clean and well kept. One person told us “Cleaners are good here, always about cleaning, nothing too much trouble.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were generally administered as prescribed, with staff seeking consent and following infection control practices. One person told us “They do ask if I am alright and if I have any pains. Not very often but they will get painkillers if I need them to.”

Some records lacked detail on treatment durations, for example one resident had a body map for a topical medicine missing. We raised this with the provider during the assessment who acted on this feedback. Controlled drug stock levels were monitored appropriately and correctly. However, there were gaps within the documentation for the collection and disposal of controlled medication.

Time-specific medicines, such as those for Parkinson’s disease, were given promptly. Staff roles were clearly defined, with a mix of registered nurses, care leaders, and healthcare assistants. Competency checks, annual observations, and refresher training was in place.

Medication storage was secure, with controlled drugs kept in locked cupboards within locked areas. Fridge and room temperatures were monitored regularly. Monthly audits and medication error analyses were carried out, and findings were acted upon. Protocols were in place for the residents.

Risk assessment and care plans were all completed and up to date. Communication with the GP surgery was effective, with weekly reviews for residents identified. Emergency medicines, such as aspirin, were available and administered only following clinical advice.