Herncliffe Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

During our assessment of this key question remains requires improvement. People did not raise any concerns with how their medication was managed. However, the home did not carry out monthly medicines audits, which would pick up on issues we found during the assessment. We found Lifting Operations and Lifting Equipment Regulations (LOLER) checks were seven months overdue. These were completed during our assessment and assurances given that equipment will be serviced every 6 months moving forward as improved governance systems were being put in place. Risks to people's safety and wellbeing had been assessed and planned. People lived in a safe environment. Systems were in place to investigate accidents, incidents, complaints. Staff and the manager communicated and worked with other agencies to help keep people safe. There were systems to help prevent and control infection.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they felt management had an open and honest culture and would investigate any safety concerns reported to them. One person said, “They are very approachable.”

The manager told us they had an open and honest culture, and they act and investigate any safety concerns reported to them. Most staff told us they could raise concerns about safety if required.

Comments included “Very approachable manager” and, “Management are really good, go as far as they can to help personally . Another staff member said, “Management are good I’ve been here 5 years not just business minded, kind and caring."

Accidents and incidents were being recorded by staff with clear details of what had occurred and what had happened in response. Some accidents and incidents had lessons learnt reviews completed my management, but not all had lessons learnt reviews in place. Audits were not robust; this had been identified by the manager with plans to introduce a new auditing system in December 2024.

People told us the transition to the home had been good with no concerns. One person told us , “It has been brilliant here from day one.”

Managers told us that there were systems and processes in place to manage the transition safely. They told us that a pre-assessment was completed prior to admission.

We received mixed feedback from staff. Most staff told us they were informed of people’s needs on admission to the home and care plans and risk assessments were put into place following their admission. One staff member said, “When we get new people in the home, we get a thorough run through of their needs.”



One staff member told us , “If a resident is admitted halfway through a medicine cycle, it is hard to get them in line with the monthly ordering system. This can lead to delays in residents getting their regular medicines on time.”

We received positive feedback from partners. Comments included, “When I first attended some years ago, they introduced an oral health guardian and as a result [person] has an oral health care plan in their rooms detailing their needs.” And , “The staff are responsive and considerate and do their best for people. They normally know them well which helps us clinicians.”

We found that effective systems were mainly in place to assess, monitor and mitigate risks to service users and keep them safe. We identified some people’s needs were not always met in respect of management of skin integrity and falls.

People who required 2 hourly checks detailed in their falls risk assessment were not always checked every 2 hours. This was not documented in their audits. However, we did not find anyone to have been harmed in relation to this.

People told us they felt safe one person told us, “Staff are professional and treat me well.”

The manager told us they were clear on their responsibilities and duties to identify and report any safeguarding concerns.

Staff we spoke to knew how to report abuse. Some comments were , “Concerns can be raised they are extremely helpful if we have to report any concerns” and , “I would go to management or then outside the home if management didn’t do anything.”

We observed that staff had raised concerns over unexplained bruising. The manger had responded to this as a complaint, however, did not report or investigate as a safeguarding concern. This was discussed with the manager.

The home had a safeguarding policy in place and safe and effective safeguarding practices in place to ensure people were protected from harm or abuse.

During our assessment we found safeguarding and complaints were investigated and responded to. The required statutory notifications had mainly been submitted.

There was one instance where a staff member had raised concerns in relation to unexplained bruising. This has been responded to as a complaint and not reported and investigated as a safeguarding concern. This was discussed with the manager to address.

People told us they felt safe with the care they received. However, people's risk was not always managed safely.

Some comments included, “Cannot praise them [staff] enough. I know mum gets the care she needs, ” and , “Everyone is so helpful and would do anything.”

Managers and staff demonstrated a good understanding of how people's needs and risks should be managed. Some comments from staff were , “Care plans are in place, and they get updated when things change.” However, we found examples were risk assessments and records of care provided required further details.

We observed people were not always checked on in relation to their times for repositioning, this could pose a risk to people’s skin management. This was not picked up by management in their governance systems. We observed safe moving and handling practices.

Risks to people's care were usually managed well. However, we found examples were risk assessments and records of care provided which required further details.

Accidents and incidents were not always consistently followed up or reviewed by management.

No concerns were raised by people in relation to the environment in feedback

The manager told us the service detected and controlled risks in the care environment. However, the management did not pick up on areas we identified and discussed during the inspection.

During the assessment inspectors observed no concerns with the environment.

The manager told us the service detected and controlled risks in the care environment. However, the management had not carried out servicing of passenger carrying equipment such as hoists within the Health and Safety (HSE) guidance of 6 months.

No concerns were raised from people or their families. Some comments included, “The staff seem busy sometimes but speak to me in a personal way, ” and “Staff can’t do enough.”

We got mixed feedback from staff around staffing levels.

Some comments were ,“There is enough staff on shift” and , “I think we are short staffed on our household, but I think we have got new staff starting.”

During our assessment we observed staffing levels appeared to be sufficient with no concerns. There were activity coordinators in the home and activities taking place throughout our assessment.

Some staff files were incomplete and missing information. Supervisions and appraisals were not always completed on time for new starters. We discussed this with the manager at the time of assessment.

People were happy with how IPC was managed in the home. They told us staff wore PPE when needed.

Staff told us they were aware of their responsibility to wear PPE.

We observed staff wearing and disposing of PPE correctly.

There was an infection control policy and process in place. The management team were clear on the procedures required and their responsibility to provide Personal protective equipment (PPE).

People did not raise any concerns with how their medication was managed.

The Manager told us they were aware of their medication management responsibilities and had a medication policy in place. However, the home currently did not carry out monthly medicines audits, which would picked up on issues found during the assessment. The home manager assured us this was to be implemented in the new year to improve their governance.

The home had measures in place to ensure people were getting their medicines on time. We did note, however, some medicines were not given due to the home not having them in stock. This did not impact people. The manager assured us they had escalated this to the GP which was evidenced on assessment.



Medicines were stored appropriately and safely. However, some improvements could be made to ensure people who received ‘as and when needed’ (PRN) medicines had more in-depth person-centred protocols in place.

We discussed the importance of medicine audits; the home manager assured us this was to be implemented in the new year to improve their governance.