Henley Lodge

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. This is the first assessment for this service since its registration. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety. Senior staff and the registered manager listened to concerns about safety and investigated safety events. Lessons were learnt to continually identify and embed good practice.

Staff discussed safety matters with people living at the service, while ensuring their views were heard, and offered suggestions on how to stay safe.

Staff knew how to report accidents and incidents, which were discussed in team meetings where learning was shared and improvements were identified. This practice showed a commitment from staff to continuously improve the service while promoting safety for people.

The service worked with people and health and social care partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

In addition to reviewing care records and discussing people’s care with health and social care professionals before people moved to the service, where possible, the registered manager met with people to get to know them and for them to get to know the registered manager. The registered manager told us, “We spend time with people, make them feel comfortable and as homely as possible. We allow them to view the place before they move in.” This ensured a smooth and safe transition when people moved between services.

The service operated systems to protect people from abuse, neglect and discrimination. Staff understood safeguarding requirements and knew how and when to report concerns.

A staff member spoke to us about the channel of reporting concerns and said, “Report to line manager and if anything is not being done, I’ll take it further, can send anonymous messages to CQC and local authority.”

People told us they felt safe at the service and were comfortable to raise concerns. For people whose freedom was restricted, appropriate legal authorisations were sought when needed.

The provider worked with people to understand and manage risks in a holistic way. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments contained clear and detailed guidance on how to support people safely while emphasising on respecting people’s choices and wishes. Risk assessments covered areas, such as mobility, smoking, going out, medicines and people’s mental health needs.

However, for 1 person, not all their identified risks were fully assessed. The registered manager rectified this immediately after the issues were brought to their attention.

We observed staff monitoring people appropriately while respecting their independence, including when they went to the garden to smoke.

People lived and received care and support in a safe environment. Facilities were well-maintained and consistently supported staff to deliver safe and effective care.

Staff carried out regular safety checks on the environment. This included internal health and safety checks, such as water temperature checks, window restrictor checks and fire door checks, as well as checks carried out by external contractors which included gas safety, electrical installation and building fire risk assessment.

Staff logged maintenance issues appropriately which the management actioned in a timely manner.

While staff attended to people’s needs safely, the service did not always make sure staff deployment was consistent. Also, people did not always have access to same sex staff as per their wishes.

The registered manager had assessed the staffing level based on people’s needs and had established 3 staff on day shifts were sufficient. However, staff rotas revealed and according to 1 person’s comments, there were several days with only 2 staff on shifts. This meant there was a risk people’s needs would not be met effectively. For example, as most people relied on staff support to go out, on some days, activities could be impacted by the lack of appropriate staffing numbers. Further, a care plan showed 1 person preferred female staff for assistance with personal care and staff meeting minutes had recorded another person would not accept care from male staff most of the time. However, despite female management staff visited the service on some days and offered personal care support to people if needed, staff rotas showed several days where a female staff member was not deployed. This indicated people requiring support from female staff were at risk of not receiving the appropriate care and support at certain times when they could have needed it. We raised this with the registered manager, and they provided additional rotas following the assessment to demonstrate that the service was adequately staffed. We will check this at the next assessment.

Staff received training in a range of areas, including safeguarding, medicines, fire safety, infection control, mental health, learning disability awareness and managing diabetes. This ensured staff had the right skills and knowledge to support people safely and effectively. Staff also received support through regular supervision and appraisal. Newly recruited staff were enrolled on an induction programme during which they received appropriate guidance and training.

The service carried out the necessary checks to ensure staff were recruited safely.

The service assessed and managed the risk of infection.

We observed staff adhering to infection prevention and control measures, including wearing personal protective equipment when performing certain tasks and using colour coded cleaning equipment to minimise the risk of cross-contamination. Staff also followed safe food handling procedures to maintain good food hygiene.

Premises, including communal lounge/dining areas, people’s rooms, the kitchen and bathrooms, looked clean. There was a cleaning schedule in place showing the different areas that were cleaned and disinfected regularly.

There were clear systems and processes in place to make sure staff managed and administered medicines safely while respecting people’s personal preferences.

The service ordered, stored and returned medicines in line with best practice and national standards. Staff completed medicines administration records appropriately. Where people were prescribed ‘when required’ medicines, there were clear protocols to guide staff on when to administer these medicines. Each person had a personalised medicines profile highlighting key information, such as the list of medicines they were on, reason for administration, doses, GP details and any particular preferences.

Staff carried out regular stock checks to minimise risks of medicine errors and mismanagement. We performed random checks on people’s medicines and found recorded medicine counts corresponded with remaining balances. Managers assessed staff practices to make sure they remained competent to manage and administer medicines.