Havendene Residential Home

Updated 12 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of 1 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The inspection team were also joined by a regulatory coordinator who was new in post and shadowing the inspection process as part of the brand-new role.

Service and service type

Havendene Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. Registered managers and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority safeguarding and commissioning teams and professionals who work with the service, including the fire service, infection control and community nurse teams. We also contacted Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

The provider was asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all this information to support our planning of this inspection.

During the inspection

We met every person at the home and either spoke to them or completed observations on those unable to share their experiences. We spoke with 8 relatives or friends to gather their feedback.

We spoke with, or contacted via email, all staff, including the nominated individual, the registered manager, cook, domestic staff and care staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included 3 people’s care records in full and parts of other people's; and multiple medication records. We looked at 4 staff files in relation to recruitment and staff support. We also viewed a variety of records relating to the management of the service, including policies and procedures.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 12 August 2023

About the service

Havendene Residential Home provides residential care for up to 25 people, some of whom were living with dementia. There were 14 people living at the service at the time of our inspection.

People’s experience of using this service and what we found

People felt safe. Medicines were well managed. The premises had undergone an extensive programme of improvements and decorating was now to be completed.

Record keeping had improved and care documentation, including risk assessments were being fully rewritten.

Quality assurance, oversight and upkeep of the service had improved. There were some areas still to work on, but an action plan was in place and being followed.

Infection control measures had improved, and the home was overall clean and tidy. The provider had some actions to take, including moving a PPE dispenser and completing the decoration of the service after the upgrade of the premises but this was in hand.

There were enough trained and safely recruited staff who felt supported. We have made a recommendation to enhance the interview process. Staff morale had improved.

People enjoyed the food and drink prepared and were offered choice. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice and records were in the process of being fully reviewed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 26 January 2023).

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We found evidence that the provider had made improvements. Please see the safe, effective and well-led sections of this full report.

Recommendations

We made 3 recommendations. These regarded reviewing and updating interview processes, ensuring accident and incident forms were fully completed and reviewing activities to ensure they meet all people's needs.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.