Henford House

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 that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Incidents and accidents were recorded and reviewed by managers to ensure actions to reduce the risk of a repeated incident were taken. Learning from incidents was shared with all staff to ensure they understood any changes to the way they needed to support people. Learning was also shared with the provider’s other services. Information from incidents was included in staff handover records, to ensure staff had key information at the start of their shift. Staff told us there was a focus on learning from events, to help ensure the service improved and incidents did not happen again.

The provider worked with people and 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 and most relatives told us systems worked well when they first moved into the home, with good communication. One relative raised a concern about the arrangements for moving in and readiness of their room. The issues were being addressed by the registered manager through the provider’s complaints process.

People’s health conditions were documented, and they were supported to access services from a range of professionals. The provider ensured information was shared appropriately with other professionals. A specialist nurse told us staff worked well with them to understand people’s specific conditions and meet their needs. Assessments completed when people started using the service ensured there was detailed information about services they were using, to make sure their support was maintained.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and relatives said they felt safe living at Henford House, with comments including, “I had fallen at home [but] I feel safe here” and “I feel very fortunate to have [moved] here.” A relative told us, “They check on [person] regularly. They don’t make her do anything she doesn’t want to do. Nothing is too much trouble.”

Staff demonstrated a good understanding of their safeguarding responsibilities and said they completed regular safeguarding training. Staff were confident managers would take appropriate action if they reported safeguarding concerns but were aware how to raise these concerns outside the organisation if they needed to. Where appropriate staff had applied to the local authority for Deprivation of Liberty Safeguards (DoLS) authorisations. The manager had a record of all DoLS applications that had been made, including details of any conditions to the authorisations.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people’s health, safety and welfare had been assessed and plans developed to manage those risks. Staff demonstrated a good understanding of the risks people faced and how to support them safely. Staff told us risk management plans were regularly reviewed and updated as people’s needs changed. Staff had immediate access to updated plans through the electronic care planning system and were notified of any changes. Staff kept records of the support they provided to people to manage risks, including ensuring people were regularly re-positioned where needed to manage the risk of pressure injuries.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People told us the home was well maintained. The provider assessed the service for risks and took action to ensure people, staff and visitors remained safe. Equipment, such as fire systems, water systems and hoists had been regularly serviced and tested to ensure they were safe. Staff told us action was taken quickly when repairs were needed.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staffing levels were determined by an assessment of people’s needs. Records demonstrated this dependency assessment was regularly reviewed, and actual staffing levels were in line with or slightly exceeded the assessed levels.

People and relatives gave us mixed feedback about staffing levels, with some positive comments including, “They check on her regularly and come instantly if she rings” and “They respond to the call bell within 5 minutes.” However, other people felt the service was sometimes short staffed and staff took a long time to answer call bells. The provider completed regular audits of call bell response times and investigated any cases where a call bell was not responded to within 5 minutes. Records demonstrated there were only 2 occasions during August 2025 where the response time was over 5 minutes. Both incidents had been investigated and action taken to improve response times. Staff told us there were enough of them scheduled on the rota, although occasionally sickness caused some difficulties which could make things feel rushed. The registered manager told us they took a “whole home approach” to covering any unplanned absences, with housekeeping staff trained to provide care for people when needed.

Required pre-employment checks had been completed for staff before starting work. New staff received an induction, including opportunity to shadow experienced staff until they were confident.

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. People told us the home was kept clean and staff followed good infection prevention and control practice, to help keep people safe. Staff said they had completed infection prevention and control training and had access to all the equipment they needed. We observed the home was clean throughout and staff were applying infection prevention and control measures, including the safe use of personal protective equipment.

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. At the last inspection we identified shortfalls in the way people were supported to manage their medicines. At this inspection we found this had improved. Staff now consistently supported people to take the medicines they were prescribed. The balance of medicines held in the service now matched the records. Equipment relating to medicines management, such as syringe drivers and blood glucose monitors, was regularly serviced to ensure they were working effectively. Liquid medicines were now labelled when they were opened and stored in line with the provider’s medicines policy.

People told us staff provided good support for them with their medicines. Staff received training in the safe administration of medicines and managers regularly observed their practice to ensure they were doing this safely. Managers completed regular medicines audits and took action to address any shortfalls.