Herondale

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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 concerns about the systems and processes not being effective to ensure good governance and oversight. The provider had not identified risk which impacted on people’s safety and welfare. The approach to learning, improvement and innovation had not included the measuring and analysis of outcomes and the impact on people. This resulted in a breach of Regulation 17 Good governance.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager and staff had a shared direction and there was a positive culture at the service. Staff met people’s needs at the direction of the person themselves. Staff knew people well and understood the challenges they faced in relation to their mental health needs. People and staff were relaxed and got on well together.

There was no system in place to ensure people and their family members were fully included and involved in the development and improvements to the service. The registered manager told us they talk to family members when they visit, but do not have a record of these conversations to monitor the input of family members and positive outcomes for people. The culture of the service respected people's individuality.

The registered manager was relatively new in post. They were open, honest and approachable and supported by a senior leader who provided guidance and supervision. However, we found the registered manager lacked some experience and knowledge to ensure people received safe care and treatment. The registered manager had not identified and acted on the health and safety concerns we had found. Staff told us they felt supported by the registered manager and able to talk to them and share ideas, their views and any concerns. A staff member told us, “We work as a team and know each other and people well. [Name of registered manager] is very supportive and available if we need them.” Family members told us the registered manager and staff were approachable, friendly and communicative. A family member said, “[Name of registered manager] is very friendly and caring. They let me know about [person’s name] wellbeing and any arrangements we need to sort out.”

Improvements were required to demonstrate there was capable leadership which ensured risks and oversight of the service were well managed. There were shortfalls relating to fire safety, infection prevention and control and people’s risk assessments. Concerns we found had not been identified through the providers auditing and quality assurance processes. The provider had not provided the registered manager with the opportunity to further develop their management experience and skills to lead the service effectively.

Staff told us they felt well supported and respected by the registered manager. Many staff had worked at the service for many years and had seen changes take place. They told us they would speak out about their views if they were not happy with anything. A staff member said, “We are lucky we have a manager who listens and works as part of the team, so I don’t have any concerns about my working arrangements or the support we give people. “

The provider had an induction, supervision and appraisal process in place which included a whistleblowing policy and procedure. Staff had received supervision meetings with the registered manager where staff could speak out and discuss their responsibilities and professional development.

There was diversity within the workforce at Herondale. Staff and the registered manager worked inclusively to ensure everyone was treated individually and had equality of opportunity. Staff members’ protected characteristics were considered to ensure their rights under the Equality Act 2010 were taken into account and did not have a negative impact on their wellbeing.

The provider had a policy for equality, diversity, and inclusion. Staff had undertaken training in equality and diversity to support wider awareness in their role. Systems were in place to seek staff feedback on their role and responsibilities, and to promote fairness amongst the staff team.

The registered manager told us that they completed checks on the quality of the care provided and had oversight of the health and safety of the service. However, they failed to identify the significant concerns highlighted within this assessment. Risk assessments were not completed for all areas of risk relating to people and the premises to ensure people were kept safe. The fire risk assessment confirmed fire extinguishers and fire blankets were provided and ready for use. The fire risk assessment was out of date and incorrect as the fire extinguishers had been removed from the premises. Staff told us, “Someone came and took them all away ages ago, couldn’t believe it really. What were we supposed to do?” Care plans did not fully reflect people’s current needs and associated risks to their mobility, choking and health and safety. There was not effective monitoring to ensure care plans and risk assessments were detailed, accurate and fully reflective of people’s needs to identify, assess and mitigate risks to their safety and welfare. Records relating to prevention and control of infection at Herondale were not maintained in line with regulatory requirements. The registered manager told us staff do the cleaning as part of their duties. We saw staff completed a weekly tick box cleaning schedule for the house and a separate one for the kitchen. These were not being audited and monitored effectively to prevent and control the risk of infection and ensure people had a safe, clean and hygienic place to live.

The systems to assess, monitor and mitigate risks relating to the safety to people, staff and visitors were not robust. There was a lack of oversight of the service as the provider and registered manager did not fully monitor and identify where improvements were needed. For example, people’s risk assessments, fire safety and bathing facilities. Governance processes were not robust enough to monitor and maintain effective management of all aspects of the service. These included systems to ensure compliance with legislation and the providers internal governance arrangements. We saw many different recording tools used by the registered manager which did not support them to easily identify and analyse risks, outcomes and lessons learnt as a result. We found health and safety checks did not include all aspects of the cleanliness and state of repair of the bathroom facilities. Quality audits were not sufficiently detailed and up to date to provide assurance that risks were being managed and improvements made. This resulted in people not receiving a standard of care and support they should expect. Legal and regulatory requirements were not consistently met, such as failure to submit statutory notifications in a timely way. These are notifications the provider must make to the CQC for certain issues such as safeguarding concerns or serious injuries.

People told us they were given opportunities to feedback about the service. We saw they were involved in meetings to discuss life at the service. We did not see any evidence of surveys being undertaken, however there was a suggestion box in the hallway which people and staff could use anytime.

Staff told us some people were ‘fiercely independent’ and came and went in the service as they pleased. They were not particularly interested in associating with particular groups or communities. Staff went out with people to the community, to the shops and places of interest.

The staff worked well with stakeholders on behalf of people using the service.

There were no systems in place for the inclusion of external communities or developing partnerships with local clubs or groups. The registered manager told us, “People are very self-sufficient and prefer their own company or that of the staff rather than strangers. One person prefers to visit Southend regularly rather than the local area.”

Feedback from staff and the registered manager did not demonstrate a focus on continuous learning, innovation and improvement across the service. There was limited evidence of creative ways of thinking to deliver positive good quality outcomes for people, however we were told about research undertaken on sweets which help people with urinary tract infections.

There were concerns identified during this assessment. The registered manager could not evidence that action had been taken to learn and improve the quality of the service. There was not a consistent approach in how to measure outcomes, utilise best practice guidance and monitor the impact and quality of care for people.