Henleigh Hall

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. This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk people could be harmed.

The service was in breach of the legal regulations in relation to people’s safe care and treatment and infection prevention and control at the service. We asked the provider to put an action plan in place to make improvements to the service.

This service scored 56 (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. Processes were in place to record, review and analyse accidents and incidents. However, some analyses of falls had not fully explored frequency linked to days of the week and an opportunity to identify learning had been missed.

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. Hospital information packs were used to ensure continuity of care and support when people transferred between services.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way for this to be achieved. 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. Members of staff were aware of how to report concerns about safety. People who lived in Henleigh Hall told us they felt safe.

We saw evidence the 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. The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found appropriate legal authorisations were in place to deprive a person of their liberty, but not all members of staff were aware of records relating to people’s DoLS status and they told us they did not look at care plans or DoLS information regularly, so they were unaware of the details. A member of staff said, “To tell you the truth, I don't look at them that often so I couldn't tell you the details.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. 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. Information in care plans was not always recorded accurately and there was, in some instances, conflicting information. For example, 1 person’s care plan stated they should not be weighed because it caused distress, however, the care plan went on to confirm the person was weighed monthly. For a person who had recently come into the care home, there was limited information about their needs and insufficient detailed information for care to be provided safely. There had been change in the electronic care planning system and whilst information had been transferred over initially, sustained work was required to review and update care plans to ensure they accurately reflected people’s needs. We were not assured care was delivered in line with people’s care plans because we were not assured people’s care plans accurately reflected people’s needs. A member of staff told us, “We have a new system that has just recently been implemented. We were given a 1-hour e-learning session and then a face-to-face session. There were many teething problems and people are still trying to learn. We raised concerns and I have had further training sessions, and more are available.” Another member of staff said, “[I am] partially trained though not competent with everything.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. 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. On the day of inspection, it was a very warm day, and fans were only available for some, but not all, people. We also identified there were some radiators on and the upstairs area above the boiler room was very warm. We raised this with the provider who took action and ordered additional fans to help keep the building cool.

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, supervision and development. They did not always work together well to provide safe care which met people’s individual needs. We observed members of staff on each of the units who were constantly on the move, providing care to people with a range of different needs. Members of staff were task-focussed and, as a result, did not always have time to engage and talk to people. A health professional told us, “You can’t find staff anywhere – there’s not enough staff.” A person who lived in Henleigh Hall told us, “There are not enough staff, they often seem very rushed.” Members of staff told us they felt staffing numbers were not always appropriate. One member of staff said, “Staffing levels sometimes are not so bad. Sometimes we could with more staff or more mixed skills. At the moment, we don't have so many residents, and I think we can manage but we are still using agency as needed.” Another member of staff told us, “I feel staffing levels have been inadequate recently, sometimes there is only 1 nurse in the building. This creates a stressful workload, for example, if a resident falls and observations are required or if we are providing end of life care. A number of our residents have complex care needs and require 2 people to care for them. If 2 carers are with a resident, it can take longer to respond to buzzers."

The provider did not always assess or manage the risk of infection and did not always detect and control the risk of it spreading. Throughout the care home storage cupboards were untidy and the floor was, in places, unclean. It could not be cleaned easily due to items stored on the floor. Kitchenette areas, fridges and food-serving trolley required a deep clean to mitigate the risk of infection and cross-contamination. Fridge seals contained food debris, and 1 fridge was not operating correctly and working temperature was too high. We asked the provider to take action to manage and mitigate this risk. Areas of the care environment were in a poor state of repair including, for example, broken radiator covers and missing wall tiles. This increased the risk of bacteria build up and spread of infection. A personal protective equipment (PPE) station was empty of gloves and aprons. Another was overfilled with aprons hanging out, increasing the risk of contamination. Staff were observed to be bare below the elbow and using personal protective equipment appropriately.

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. There was a lack of adequate cooling for treatment rooms where medication was stored. However, people who lived in Henleigh Hall told us they received their medication at the correct times. One person said, “I have Parkinson’s, so I have to have my medications at the right time. I always do get it right because it’s important.”