Havengore House Residential Care Home

Updated 17 February 2022

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 Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. 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 was completed by one inspector.

Service and service type

Havengore House Residential Care 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. 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.

What we did before the inspection

We used the information the provider sent us in the provider information return [PIR]. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the Local Authority. We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service about their experience of the care provided. We spoke with one member of staff about what it was like to work at Havengore House Residential Care Home. We also spoke with the registered manager, deputy manager and the provider. We reviewed a range of records, including five people's care records and two staff personnel files. We also looked at the provider’s quality assurance and auditing arrangements.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We spoke with three people’s relatives about the quality of care received for their family member. We also spoke with three members of staff.

Updated 17 February 2022

About the service

Havengore House Residential Care Home is a residential care home providing the regulated activity of personal and nursing care for up to 22 people. The service provides support to older people and older people who may be living with dementia. The care home accommodates people in one adapted building and at the time of our inspection there were 19 people using the service.

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

People were safe and liked living at Havengore House Residential Care Home. Suitable arrangements were in place to protect people from abuse and avoidable harm. Staff understood how to raise concerns and knew what to do to safeguard people. Staffing levels were appropriate to meet people’s needs and staff were recruited safely. Medication practices at the service ensured people received their medicines as they should, and staff were appropriately trained. People were protected by the service’s prevention and control of infection practices. Findings from this inspection showed lessons were learned and improvements made when things went wrong.

People’s care and support needs were documented, and staff had a good understanding and knowledge of people’s needs and the care to be delivered. Information relating to people’s end of life care needs was recorded and the registered manager knew how to access support from the local palliative care team. Suitable arrangements were in place to enable people to participate in social activities. Complaints were well managed and a record of compliments to capture the service’s achievements was maintained.

Quality assurance arrangements enabled the provider and registered manager to monitor the quality of the service provided.

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

Rating at last inspection and update

The last rating for this service was requires improvement [published 8 May 2019].

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 4 March 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve receiving and acting on complaints Regulation 16 [Receiving and acting on complaints].

We undertook this focused inspection to check they 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 of Safe, Responsive and Well-Led which contain those requirements.

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. This is based on the findings at 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. This included checking the provider was meeting COVID-19 vaccination requirements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Havengore House Residential Care Home on our website at www.cqc.org.uk.

Follow up

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