Henleigh Hall

“Processes were in place to record, review and analyse accidents and incidents. People who lived in Henleigh Hall told us they felt safe. We saw evidence the provider understood the principles of the Mental Capacity Act 2005 (MCA) to review people’s capacity and understanding around receiving care and support. However, we saw examples in some care plans where assessments of capacity and decisions made in people’s best interest were not recorded. People’s care plans were not always person-centred and there was information missing about people’s preferences in relation to how they wanted their care and support to be provided. The care environment was not always safe. Some people’s rooms were very cramped, and storage of equipment did, at times, make it difficult to access bathrooms. The provider did not always assess or manage the risk of infection and did not always detect and control the risk of it spreading. The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. We reviewed a range of medication administration record (MAR) charts and identified there were errors in some stock counts of medication. Risk assessments for the use of emollient, paraffin-based creams were not always in place.”

“People's needs were assessed in their care plans, but care was not always delivered in line with these assessments. Care records for people who were at risk of weight loss were not always updated with information about their nutrition and hydration. People with specific health conditions were seen by specialist clinical teams to ensure their care needs were being met and to monitor and review any changes. Some people’s mental capacity to make informed decisions was not always recorded and reflected in their care plans and, subsequently, decisions made in their best interest were not always recorded.”

“Staff appeared kind and caring and understood people's needs. However, they were task focused and very busy. The provider generally promoted people’s independence, so people knew their rights and had choice and control over their own care, treatment and wellbeing. However, we observed some examples where people were not provided with choice and opportunities to maintain their independence, including the provision of specialised cutlery. The provider cared about and promoted the wellbeing of their staff and but did not always support and enable them to deliver person-centred care.”

“The provider did not always make sure people…”