Hengoed Park

Updated 14 March 2024

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.

Inspection team

This inspection was completed by 2 inspectors on our first and second day, and 3 inspectors on our third day.

Service and service type

Hengoed Park 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. Hengoed Park is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Hengoed Park is also a domiciliary care agency. It provides personal care to people living in their own houses and flats. No one received this service at the time of our 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 a registered manager in post.

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 local authorities, local Healthwatch and professionals who work with the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.

During the inspection

We spoke with 12 service users, 3 visitors and 15 staff which included housekeeping staff, care staff, the registered manager who is also the nominated individual, kitchen staff, the deputy manager and maintenance staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included 7 people's care plans, multiple medicine administration records and 3 staff recruitment files. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

Updated 14 March 2024

About the service

Hengoed Park is a residential care home providing accommodation and personal care to a maximum of 44 people. These residential care home beds are in the main home and 8 bungalows on site. At the time of our inspection there were 44 people using the service.

Hengoed park is also registered with us to provide a domiciliary care service, accommodation for persons who require treatment for substance misuse and treatment of disease, disorder or injury. No one was receiving these services at the time of our inspection.

The service provides support to younger adults and older people who may have mental health support needs, dementia, who misuse drugs and alcohol, are detained under the Mental Health Act or have a physical disability.

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

People's medicines were not managed safely at all times. People were not always protected from environmental risks, although the provider had refurbishment plans in place and work had already started throughout the home to make improvements.

We have made a recommendation about the recruitment of staff because the provider had not ensured the correct information had been recorded. This was addressed at our inspection.

Risks to people were assessed and planned for so staff could support people to stay safe. However, improvement was needed to ensure staff recorded accurate information when they had repositioned people to reduce the risk of skin damage.

Records did not demonstrate people’s voice was sought and what their expectations were for their care and goals. Governance systems were not always effective at identifying concerns within the service, such as people’s records, staff training records, staff recruitment and medicines.

There was minimal provider scrutiny or oversight of the governance arrangements within the service. The registered manager was also the nominated individual. The provider had failed to ensure all notifiable incidents were reported to us as required.

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 generally supported this practice.

People were supported by enough staff. Most people told us they felt safe living at the home and with the staff who supported them. We received mixed feedback from people who used the service, staff and external professionals about their experiences of the service.

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 good (published 2 February 2019).

Why we inspected

We received concerns in relation to people’s care and that the provider was not operating within the scope of their registration. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 good to requires improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for Hengoed Park on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to medicines management, governance, and failure to notify us about reportable incidents at this inspection. We also made recommendations regarding the recruitment of staff and the need to work with the local authority to clarify the service, contracts and funding people receive.

Please see the action we have told the provider to take at the end of this report.

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 work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.