Background to this inspection
Updated
16 July 2021
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 an 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.
Service and service type
Henley Manor 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. This means that they 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. Inspection activity started on 17 May 2021 and ended on 26 May 2021. We visited the service location on 19 May 2021.
What we did before the inspection
We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. The provider was not 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 the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We looked at notifications received from the provider. A notification is information about important events which the provider is required to tell us about by law. This ensured we were addressing any areas of concern. We remotely looked at five people’s care plans. We also reviewed the providers quality assurance systems. We received feedback from 11 relatives about their experience of the care provided. We used all of this information to plan our inspection.
During the inspection
We spoke with 10 people who used the service. We looked around the home and observed the way staff interacted with people. We looked at four medicine administration records (MAR). We spoke with six members of staff including the registered manager, deputy manager, a nurse, carers, the chef and a member of the Lifestyle team. We looked at five recruitment and training records as well as health and safety processes.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We received feedback from four healthcare professionals. We also corresponded with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
Updated
16 July 2021
About the service
Henley Manor is a residential care home providing personal and nursing care to 33 people aged 65 and over at the time of the inspection. The service can support up to 80 people.
People’s experience of using this service and what we found
People living at Henley Manor were supported to lead purposeful lives, engaging with their families and the local community. Whilst adjustments had been made due to the restrictions of the Covid-19 pandemic, measures had remained in place to ensure meaningful relationships and people's overall health and wellbeing was maintained.
People had excellent opportunities and access to a variety of activities to prevent social isolation. Social activities met people's individual needs and followed best practice guidance so people could live as full a life as possible. Activities were overseen by a committed, passionate and experienced staff team.
The service has gone the extra mile to find out what people had done in the past, evaluated whether it could accommodate activities, and made that happen. The service had gone the extra mile to encourage and support people to develop and maintain relationships with people that matter to them. The service took a key role in the local community and was actively involved in building further links with the local community. Contact with other community resources and support networks was encouraged and sustained. Local schools had links with the home, with pupils and people visiting each other's establishments. People told us they enjoyed and benefitted from these links.
The service worked closely with healthcare professionals and provided excellent end of life care. People experienced a comfortable, dignified and pain-free death. We saw feedback from relatives following end of life care was commendable. Staff had the specific skills to understand and meet the needs of people and their families in relation to emotional support and the practical assistance they needed at the end of the person’s life. Records showed staff had attended end of life care training. Staff told us they were supported by the management team with empathy and understanding.
Staff knew how to identify and report any concerns. The provider had safe recruitment and selection processes in place which incorporated their values.
Risks to people's safety and well-being were managed through a risk management process. There were sufficient staff deployed to meet people's needs. Medicines were managed safely, and people received their medicines as prescribed.
People and relatives told us staff were caring. Staff did all they could to promote people’s independence and we saw examples of this. People received personalised care, tailored to their individual needs and preferences, and staff supported people and their relatives to be involved with decisions relating to their care. People's privacy and dignity was upheld through the approaches taken by staff as well as in relation to the care environment, as people each had access to their own bedrooms with ensuite bathroom facilities.
People had a pleasant well-presented dining experience which offered a variety of appetising food choices available at times that suite people’s preferences. Staff supported people to maintain food and fluid intakes, including, through the use of snacks, and making people hot drinks during the night to help them relax and maintain their comfort. There were hydration points and bottles of drinks freely available and placed at many accessible areas.
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. Staff had a particularly good understanding of when the principles of the Mental Capacity Act should be applied. People were supported to meet their nutritional needs and complimented the food at the home.
The home was well-led by a registered manager who was committed to improving people’s quality of life. The service had a clear management and staffing structure in place and staff worked well as a team. The provider had effective quality assurance systems in place that included the use of technology to monitor the quality and safety of the service. Staff worked well with external social and health care professionals.
Rating at last inspection
This service was registered with us on 2 February 2020 and this is the first inspection.
Why we inspected
This was a planned 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.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk