16 January 2024
During an inspection looking at part of 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.