During an assessment under our new approach
Date of assessment: 26 May – 26 June 2026. We visited the service on 26 May 2026 and reviewed the care and support people received along with their care records and management information. Henleigh Hall provides residential and nursing care to older people. Some people using the service were living with dementia. Henleigh Hall can accommodate up to 62 people. On the day of inspection there were 50 people living in the service. 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. CQC regulates both the premises and the care provided, and both were looked at during this inspection. We carried out a comprehensive inspection of the service under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. The reason for the assessment was due to risk because of concerns we received about the service, and it did not have a rating because the provider organisation had changed in September 2025. In this assessment we looked at all the quality statements in all the key questions. The outcome of the inspection was a rating for the service.
The provider was in breach of legal regulations in relation to infection prevention and control, people’s safe care and treatment and governance of the service. We asked the provider to put an action plan in place to make improvements to the service.
Processes were in place to record, review and analyse accidents and incidents. People who lived in Henleigh Hall told us they felt safe. We saw evidence the provider understood the principles of the Mental Capacity Act 2005 (MCA) to review people’s capacity and understanding around receiving care and support. However, we saw examples in some care plans where assessments of capacity and decisions made in people’s best interest were not recorded. People’s care plans were not always person-centred and there was information missing about people’s preferences in relation to how they wanted their care and support to be provided. The care environment was not always safe. Some people’s rooms were very cramped, and storage of equipment did, at times, make it difficult to access bathrooms. The provider did not always assess or manage the risk of infection and did not always detect and control the risk of it spreading. The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. We reviewed a range of medication administration record (MAR) charts and identified there were errors in some stock counts of medication. Risk assessments for the use of emollient, paraffin-based creams were not always in place.
People's needs were assessed in their care plans, but care was not always delivered in line with these assessments. Care records for people who were at risk of weight loss were not always updated with information about their nutrition and hydration. People with specific health conditions were seen by specialist clinical teams to ensure their care needs were being met and to monitor and review any changes. Some people’s mental capacity to make informed decisions was not always recorded and reflected in their care plans and, subsequently, decisions made in their best interest were not always recorded.
Staff appeared kind and caring and understood people's needs. However, they were task focused and very busy. The provider generally promoted people’s independence, so people knew their rights and had choice and control over their own care, treatment and wellbeing. However, we observed some examples where people were not provided with choice and opportunities to maintain their independence, including the provision of specialised cutlery. The provider cared about and promoted the wellbeing of their staff and but did not always support and enable them to deliver person-centred care.
The provider did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs. The service worked with other health professionals involved in people’s care. The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.
The provider had a shared vision, strategy and culture. However, it was not clear the staff team were supported effectively to understand and implement the provider’s vision. The provider did not always have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. The provider had systems and processes to review and monitor quality in the service; however, the issues identified throughout the inspection had not been identified by the registered manager or the quality assurances processes in the care home.