Herondale

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• 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, we found various concerns including the management of risks to people’s health and wellbeing, fire prevention systems and infection prevention and control. This resulted in a breach of Regulation 12 Safe care and treatment. We found concerns around the environment in which people lived including the lack of safe bathroom facilities which resulted in a breach of Regulation 15 Premises and equipment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not always safe living at the service. We observed people were at risk of harm due to lack of health and safety, for example fire extinguishers and cleanliness of the service. We saw examples where people’s safety had not been fully investigated such as a person's reduced access to the community.

Feedback from staff and registered manager showed there were inconsistencies in the approach to safety as events were not investigated robustly or monitored regularly. The registered manager told us they were open to feedback and showed a willingness to make improvements.

The management and oversight of safety at the service was not adequate. Not all risks were identified and acted on appropriately to ensure people’s safety was monitored and reviewed. The registered manager could demonstrate some learning, and improvements had been made around people’s safety, but systems were not in place to identify and act on all safety concerns.

Some people had lived at Herondale a long time and were happy there. Others were new to the service. People’s experience of moving to Herondale had been positive. A person said, “I have settled in well and feel okay.”

The registered manager told us they provided continuity of care to people. For example, when they went in and out of hospital and when new people arrived. There was a pre-assessment pathway in place to ensure any new person was suitable and the staff could meet their needs. Staff knew people well and liaised with healthcare professionals as and when required on behalf of the people they supported.

There was good communication with health and social care professionals. A professional told us, “The staff liaise with me about [person’s name] very well.”

Safety was not always managed, monitored and assured. Some care plans did not provide correct information such as people’s personal emergency evacuation plans [PEEP] which had a potential to impact on information sharing with other services in an emergency, such as paramedics and the fire and rescue service.

People told us they were safe. A person said, “Yea I am okay, they help me out.” Family members were satisfied with the support given to their relatives and understood the balance of ensuring their rights and freedoms were maintained whilst supporting them with information and guidance about keeping safe. A family member said, “There is no bullying, and everyone seems to get on well. The staff will let me know if they have any worries about [person’s name].”

The registered manager was aware of their responsibilities to report safeguarding concerns to the local authorities they worked with. Staff had received training in safeguarding people from abuse. Staff told us where they would report any safeguarding concerns to, such as the local authority and the police. They felt the registered manager would deal with any allegations or incidents of abuse quickly.

We observed people’s rights and freedoms were respected. Where people’s rights were restricted, these had been assessed and appropriate authorisation was in place.

There were safeguarding processes in place with clear policies and procedures to protect people from abuse. We saw a safeguarding concern had been investigated and a lesson learnt as a result. The registered manager told us they contacted the person’s local authority over the telephone to check if a safeguard was required. However, these conversations were not recorded with the agreed action taken to show how people were being protected. We spoke with the registered manager about this, and they agreed to put a system in place to record all necessary information related to the safeguarding of people living at the service.

People were involved in their plan of care, to varying degrees. We saw they had signed their agreement, where they could. However, we observed not everyone was involved in finding solutions to identified risks and things that mattered to them, for example people with mobility difficulties not being able to access the community. Family members told us that the staff updated them on information about their relative, but they had not seen a copy of their relative’s care plan or been involved in any reviews undertaken. “I wouldn’t mind knowing what their plan of care entailed, but as long as they are being looked after, it’s okay.”

Staff told us they consulted and involved people in all aspects of their care. They gave us examples of where people had agreed to be supported in an individual way for example to manage their smoking. A staff member told us, “We know people very well and support them to try to manage with the day-to-day things. We also know when it is a struggle for them to keep to a routine and remind them of why this is important for them.”

Our observation of staff found that they supported people in a way that was supportive and encouraging.

Processes were not always effective in ensuring there was correct information recorded about people’s involvement in their care and support. We identified some care records which were incomplete, contradictory, and inaccurate. This included people’s risk of choking, risk of smoking and personal emergency evacuation plans.

People did not experience a safe place to live as they were not protected against the risks of fire as no fire extinguishers were available in the service. People did not have access to safe, hygienic and clean bath or shower facilities. People had been tolerant of this and had been waiting since 2021 for 2 out of the 3 bathrooms to be replaced. All bathrooms were in a state of disrepair, and not maintained to an acceptable standard, this included shower chairs, curtains and hoses and the bath panel was not secured and safe.

The registered manager and staff told us the fire extinguishers had been removed some months ago, with only the fire blanket kept in the kitchen. The registered manager and staff told us the fire extinguishers were removed because staff were not trained in their use. This left people, staff and visitors at risk of not having adequate fire safety equipment available in the event of a fire. Following our visit, the provider acted and arranged for the reinstatement of the correct number of fire extinguisher needed for the service. The registered manager told us one bathroom had been refurbished in 2021, but the other 2 bathrooms needed attention and were due to be refurbished. Two of the bathrooms were being used by people, one upstairs used by two people and the one downstairs being used by 5 people. The bathing and washing facilities to help people maintain and manage their personal hygiene needs at Herondale were not up to an accessible standard.

People had access to and shared all areas of the service, including the kitchen, dining room and lounge. People’s bedrooms were personalised with their belongings. A person told us, “I have a nice bedroom, thank you, it’s all good.” A family member told us, “I think there is enough space for people to share together and [person’s name] bedroom is okay for them. “

The provider had failed to ensure effective arrangements were in place to monitor the fire safety of the premises. The providers fire audits failed to identify the lack of fire extinguishers and why they had been removed from the premises. Adequate fire safety signage was not in place to direct people in the event of a fire. There were significant risks to people, staff and visitors to the service from poor fire safety and the lack of a plan to prevent and control a fire and the potential risks this posed. Audits of health and safety were inadequate and did not identify and monitor the poor state of the bathrooms which people had to use. People were at risk of using unsafe equipment which placed people at risk of harm and discomfort.

There was enough staff to care for people. Family members told us there was always a staff member to talk to when they visited and usually this was a familiar face who knew their relative well.

Staff told us there was enough staff to support people and they were a consistent team as they had worked together a long time. They told us there was good communication, clear handovers and the registered manager was supportive. A staff member said, “It is a great place to work, people are lovely, and we know each other so well, like a family.” Another told us, “We have to do training, usually online and [name of registered manager] checks how we do the medicines. The rotas work well, we know what we are doing, and we cover each other when needed. “

We observed enough care staff supporting people around the service. Staff were knowledgeable and competent in supporting people to go about their daily lives, knew their individual personalities and what they liked and disliked. People and staff were comfortable in each other’s company.

Staff had completed training relevant to their roles and responsibilities. Staff told us about the training they had which had been online. A staff member said, “It’s always good to have a refresher so we keep up to date on things.” Staff supervision and competency checks were in place to ensure staff remained competent and supported in their role. The provider had a recruitment process in place. All the necessary documentation was obtained except we found some gaps in staff members’ employment history. We made the registered manager aware of this so it could be amended to meet the requirements.

The provider failed to ensure people were protected from the risk of infection. People were exposed to unsafe infection prevention and control practices. At least 5 people had to share a shower mat that was visibly dirty; walk on stained floors in the bathrooms; use shower curtains, toilets and toilet brushes which were unclean and stained and bins with no bin bags inside or lids. People were assisted to clean and tidy their bedrooms with support if needed. A family member said, “I think [person’s name] keeps their room as they like it as they like things organised.”

We talked with staff about the bathroom facilities available to people using the service. A staff member said, “I wouldn’t want to use the bathrooms the state they are in.” Care staff were responsible for cooking, laundry and cleaning tasks as part of their role and responsibilities. However, staff had not observed the uncleanliness and the build-up of dirt and stains in the bathrooms people used. A staff member said, “We all just muck in and keep things tidy as we go along.” Staff told us they had personal protective equipment [PPE] available and showed us a box of gloves in the office which they used when needed.

We observed the bathrooms were in a state of disrepair and at the time of the assessment had not been cleaned. Mops and buckets were left in the corridor by the kitchen after being used and not put away. The kitchen was maintained to a satisfactory standard.

The providers' systems to monitor and manage the risk and spread of infection were not effective in maintaining the service to an acceptable level. Both daily cleaning records and the registered managers weekly check on the cleanliness of the premises failed to identify the concerns we found. The policy and procedure for managing the risk and spread of infection had not been updated and was not fit for purpose. Following our visit, the registered manager informed us improvements had been put in place to address our concerns.

People were given their medicines as prescribed. They were called to the office to have their medicines. Their choices about how they liked to be given their medicines and their capacity to manage them was recorded. Staff were aware of people’s rights to decline medicine and the process to follow should this occur. A family member said, “The staff makes sure [person’s name] gets their medicines which is really important.” Another family member said, “The staff are sometimes a bit loud when they call out for someone to get their medicines, they could tone it down a bit especially when people are visiting.”

Staff were trained to provide people with their medicines. We saw competency checks had been undertaken. The staff member we observed knew who had medicines, what type and when they took them. They were able to explain how to complete the medicine administration record [MAR], identify allergies, explain codes and the process for when people took medicines ‘as and when’ required.

The provider had an up-to-date medicines management policy in place. Medicines were stored safely and appropriately. Staff completed appropriate records when supporting people with their medicines and there were regular audits in place.