Hen Cloud House

Updated 2 September 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 Health and Social Care Act 2008.

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 was carried out by 2 inspectors 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

Hen Cloud House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Hen Cloud House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

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 (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 16 people who used the service and 3 relatives. 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.

We spoke with 11 members of staff including the operations director who is the nominated individual, a registered manager from one of the provider’s other services, the area manager, the deputy manager, a senior care worker, 5 care workers and the activity coordinator. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed 7 people's care records, 5 staff files and multiple medicine records. We also looked at a variety of records relating to the management of the service, including policies and procedures.

Updated 2 September 2023

About the service

Hen Cloud House is a residential care home providing personal care for up to 66 people. The service provides support to older people, some who may have a diagnosis of dementia, a physical disability, or a sensory impairment. At the time of our inspection there were 43 people using the service.

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

People’s risks were not always managed safely. The management of medicines required improving and lessons were not always learned when things went wrong. Staff did not always feel there were enough staff to meet people’s needs effectively.

There was no registered manager in post. The governance systems in place were not effective to monitor the quality and safety of the service. Some records needed reviewing and updating and were not always person centred. Staff said they did not always know how to effectively meet people’s needs.

There was not always sufficient time or support to allow people to follow their interests or provide engagement opportunities. Records were not always person centred. Engagement with people, relatives and staff needed improving. There was a complaints policy in place although some people did not know how to make a complaint.

People were supported to have maximum choice and control of their lives and staff did support them in the least restrictive way possible and in their best interests; however, the policies and systems in the service did not support this practice.

People were protected from abuse. People were protected from the risk of infection. Staff demonstrated a kind and caring approach which respected people’s privacy and dignity.

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

Rating at last inspection

This service was registered with us on 2 March 2023 and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about medicine management, staffing levels and the health and wellbeing of people living at Hen Cloud House. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements.

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.

Enforcement

We have identified breaches in relation to regulation 11 (consent), regulation 12 (safe care and treatment) and regulation 17 (governance).

We have issued the provider with a warning notice. We will check the provider is taking action to comply with the legal requirements set out in the warning notice.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will continue to monitor information we receive about the service, which will help inform when we next inspect.