We carried out a review of the data available to us about Hallmark Henley Manor Luxury Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Hallmark Henley Manor Luxury Care Home, you can give feedback on this 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
We found the following examples of good practice.
The provider had invested in the most effective antibacterial product available that gives a 24-hour protection on the skin and protects hard surfaces for 30 days against Covid-19. The product has been developed to the highest standards and was tested in the accredited laboratories. There was sufficient stock of appropriate personal protective equipment (PPE) and it had been checked by the regional team to ensure it complied with the quality standards. Staff participated in various training sessions around infection control and using PPE. The team developed their own assessment tool used to determine staff’s competency around infection control and PPE and they shared it with external professionals as an example of a good practice.
Significant consideration had been given to the impact of the lockdown on people’s wellbeing and the provider signed up to an external protocol to assess it. The protocol focussed around those living with dementia and other frail people, who benefit from the nurture of a family member or trusted friend. Risk assessments were carried out for group activities to ensure social distancing was observed and people received social stimulation. The provider’s 'Lifestyle' care plan included a designated assessment to identify people at risk of social isolation so that actions could be put in place to reduce and manage the risks.
A visiting suite had been installed in the garden to safely facilitate relatives’ visits on a pre-booking basis. A limited number of visitors was encouraged with consideration given to allow time for disinfecting the area in between visits. On arrival to the service, infection control procedures were explained to any visitors and a declaration form completed which included the temperatures taken at the time. Visitors were provided and required to wear the appropriate PPE in line with government guidelines. A new technology system had been designed by the provider and used to maintain effective communication between people and their families. This included video calling, sharing of photos or music to encourage conversations and memories.
The provider had robust systems to ensure safe admissions, including only allowing new admissions after a confirmed negative result of the Covid-19 test. The provider had also assessed the environment, with consideration given where to allocate people should they need to isolate. This included identifying ground floor bedrooms to ensure access to the garden and that people would not be only confined to their bedroom. An additional cleaning schedule had been introduced to ensure robust measures to reduce infection risks, including additional tasks such as cleaning of any regular touchpoint surfaces.
The provider took part in the pilot Covid-19 testing of a care staff programme and ensured regular testing took place thereafter. Impact assessments to ensure appropriate support for staff had been carried out, these included individual health conditions and personal circumstances. Staff had access to dedicated counselling and advice if they been affected directly or indirectly by Covid-19.
Additional, regular communication took place. This included a weekly update for people and their relatives to share the current ‘Covid-19 status’ of the service and any changes to the visiting policy. Also, a regular newsletter for staff with updates and thanks for their work and commitment to keeping people safe. Staff praised the management team, comments included; “I think they did the right thing from the very beginning, including the decision to close to visitors at the right time. They listened to staff and our worries” and “We were very vigilant and very strict. I feel 100% supported.”
Further information is in the detailed findings below.