Henley House

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 that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Staff and leaders at the service were open and honest when something had gone wrong and had made proactive steps to put things right so they didn’t happen again. The registered manager and nominated individual undertook investigations when things had gone wrong and were proactive to ensure people’s safety. The registered manager told us, “I fully investigate to understand what has happened. To learn from this, I share the outcome and what we need to do different in the future with staff. This is verbally, in meetings and during handovers.” Where events or incidents had occurred, the provider worked in an open and transparent way to welcome suggestions on how it could improve. These suggestions were consistently acted upon to ensure care was high quality.

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.

The provider had systems in place which helped ensure people received safe care, including when they moved between services. Preadmission assessments were completed together with people, their relatives and other professionals which helped ensure the provider was aware of and able to meet people’s needs. A visiting professional told us, “The staff are great here. They are always available to talk things through. The care is good.” Pre-admission assessments were completed to make sure the service was able to provide the right care. One staff member told us, “We have 23 people living here. We are full and we have a waiting list too.” A relative told us, “I was involved in the initial care plan. I told staff about the way my [relative] likes to spend their day.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. The provider shared concerns quickly and appropriately.

People were protected from the risk of abuse or neglect. Where incidents had occurred, the provider and registered manager had been proactive to take steps to protect people from further risk of harm. The registered manager told us they have been working closely with partner organisations to learn and make sure they are following the right processes. Largely, people, their relatives and most visiting professionals told us people were protected from safeguarding concerns. However, one visiting professional said, “I have had a lot of involvement at the home due to unexplained injuries, poor practice and concerns raised. While some of these were not proven, we have found areas which were proven where care fell below the expected standard.” We found the registered manager was proactive in continuous improvement to develop and grow the service where safeguarding incidents had occurred, and current practices now keep people safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service worked with people and their relatives to understand known risks. The registered manager has been working with staff to ensure risks were anticipated in a more consistent way and how to respond if something happened. People were supported to take risks and make choices in line with their wishes. Staff were aware of risks to people. One member of staff told us, “The care plans and risk assessments are really good. They give me the information I need.” We found examples of the registered manager sharing important reminders to staff about managing risks. For example, staff were reminded about the fire risk associated with emollient based creams and how to manage this.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We found the environment was clean and hygienic, but areas of the home would benefit from renovation. For example, we found some lino was lifting in some rooms and some carpets were worn. Leaders at the service told us how they are proactive in repairing and replacing damaged flooring and told us some carpets which were damaged were “only 18 months old.” Despite this, the provider was organising repairs and replacements in high traffic areas where damage had occurred. There was an ongoing programme of maintenance to ensure the service was safe and suitable for people to live in. The registered manager was proactive on identifying and reminding staff of keeping the environment accessible for everyone. We found fire safety records and checks to hoists were completed routinely.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff to provide safe care to people. While the service had access to temporary staff in cases of urgency, we found there was a consistent staff team who were passionate and committed to providing high quality care. We found some staff needed to complete refresher training however the registered manager was actively monitoring and managing this to ensure staff had the up to date skills to provide safe care. People felt there were enough staff. One person told us, “The carers always have a friendly smile on their face.” And another person told us, “It’s the same carers. They are all so friendly and kind.” Staff felt there were enough staff to provide safe care. One member of staff told us, “We used to be short in the mornings, but they put extra staff on. It’s ok now.” While another staff member said, “Yes, there is enough staff. It’s fine.” Staff were safely recruited with checks completed to make sure they were safe working at the service. Staff had regular supervisions with the manager.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service assessed and managed the risk of infection. There were audits and checks in place to make sure staff were safely managing the risk of infection transmission. Housekeeping staff worked hard to ensure the service was kept clean. We observed staff using personal protective equipment (PPE) throughout the inspections and staff were found to consistently wash their hands before and after caring for someone. One relative told us, “I do feel in the last 12 months, it feels cleaner and brighter.” While another person told us, “It is a nice place. It is very clean.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were managed by staff who had been trained and had their competency assessed. Medicines were stored securely however monitoring of temperatures of storage areas were not escalated when it was outside of the recommended range; this meant there was a risk medicines were not safe to give to people.

For one-person prescribed powder to thicken drinks to prevent choking, we found it’s use was not always recorded.

For people who had their medicines crushed prior to administration this wasn’t always documented in the care plans, and staff did not always follow the written instructions to ensure these medicines were administered in an appropriate way.

For people prescribed medicines patches there was not always a record of where this was applied on the body. This meant we could not be assured the application of the patch had been rotated in line with manufacturer’s instructions. For medicines to be administered ‘when required’ (PRN), person centred protocols where in place. These provided staff enough information to administer these medicines appropriately.

Following the inspection, we received assurances from the provider improvements had been made.