Herncliffe Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

During our assessment of this key question, we found the rating has changed from Good to requires improvement. Governance systems were not robust enough to monitor aspects of the service. The manager, however, had started to address these at the time of inspection. The manager had promoted a good culture which focused on people’s individual needs. Staff spoke positively about the manager and told us they were approachable and caring. Management sought feedback from people and family members and made improvements where necessary. 

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager told us they have a vision which is based on been open and transparent. The manager told us they are a respectful provider and trying to learn and improve in areas where needed. They told us they knew they did not have robust governance systems in place, and this was something they were looking to improve on and working on. Staff told us audits were not always completed. One comment was “Auditing is still not been completed, although I thought this would be by now, this does not seem a priority with the manager.”

The service provided evidence of staff meetings taking place. Staff overall told us they are listened to in meetings.

Leaders had been working to embed changes in how the home was run. A new manager was in post. There were mixed reviews about the leadership in place. Some staff did not feel able to speak up and feared reprisal. Other staff said they had experienced positive interactions with leaders and felt listened to.

The provider had systems in place to capture the views of staff, such as staff meetings and supervisions. However, further development of these systems was needed to ensure they were incorporated in their quality assurance processes to enable feedback to be captured fully and acted upon.

Management told us that they fostered a positive culture where people felt that they could speak up and that their voice will be heard. Most staff told us they would speak up if needed to.

The manager needed to improve some areas to formally capture the views of all staff, such systems needed to be operated in an open and transparent way. The provider was aware of this.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The providers quality audits did not always have managerial oversight. The registered manager acknowledged a more robust governance system was needed.

Accidents and incidents were being recorded by staff with clear details of what had occurred and what had happened in response. However, accidents and incidents were not always audited. The current system during assessment was not satisfactory with audits been completed as part of "resident of the day" but these were not always been completed and there was not a robust system in place to "follow up" on missed information nor was there detail and direction on how to complete the audit. For example, "review care plan" the current audit does not state what to review, why and what a "good" and what a "poor" care plan would look like.



Staff file audits were not completed by management.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The manager told us that they were aware of how to report, safeguard and investigate events and incidents and gather lessons learnt from incidents to improve.

The manager had started to implement processes to ensure that lessons were learned when things went wrong, and good practice was shared.