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Inspection Summary

Overall summary & rating


Updated 10 November 2018

Herncliffe Care home is a ‘nursing home’. People in nursing homes receive accommodation and nursing care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home provides nursing and personal care for up to 129 older people, some of who are living with dementia. There were 119 people using the service when we inspected. The home has six separate wings; Garden wing provides nursing care for up to 24 people living with dementia; Margaret wing provides nursing care for up to 23 older people; Terraces provides nursing care for up to 26 older people; Constance wing provides nursing care for up to 24 older people living with dementia; Alexandra wing provides personal care for up to 17 older people living with dementia and Victoria wing provides personal care for up to 14 older people. Each wing has its own communal areas including lounge and dining space.

The inspection took place on 9 and 15 October and was unannounced. At the last inspection in June 2017 we rated the service Requires Improvement. We found breaches of regulation relating to person centred care, safeguarding service users from abuse, staffing and good governance. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions, Is the service Safe?, Is the service Effective?, and Is the service Well Led? to at least good.” At this inspection we found improvements had been made and the service was no longer in breach of any regulations.

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Overall we found the service provided high quality care and support. People who used the service, relatives, healthcare professionals and staff provided good feedback about the home and said people’s care needs were met. Some further improvements were needed to the safety of the service, namely ensuring there were consistently enough staff on duty throughout the home and ensuring the administration of topical medicines such as creams was done in a consistent way. These issues had already been identified by the management team and plans were in place to address them.

People were safeguarded from abuse and improper treatment. Well understood policies were in place to protect people from harm. People said they felt safe and secure living at the home. Overall, risks to people’s health and safety were well managed. Risk assessment documents were in place to guide staff. Staff we spoke with knew people well and the risks they were exposed to.

Most medicines were safely managed and given as prescribed. Better systems were needed to ensure the administration of topical medicines were recorded in a consistent way.

The premises were suitable for their purpose and had been adapted to meet people’s individual needs. The home was clean and odour free.

Staffing levels were sufficient in most areas of the home, although they required review in Margaret wing and at mealtimes. Staff were recruited safely. Staff received a range of training and developmental opportunities and told us they felt well supported.

The service had a good understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards and acted within the legal framework. People were involved in decision making to the maximum extent possible.

People’s nutritional needs were met by the service. People had access to a suitable range of food. On the first day of the inspection we found some aspects of the mealtime experience needed improving. This had been rectified by the second day of our visit.

People had access to a range of professionals to ensure their healthcare needs were met. We saw good partnership working had been developed between the home and other professionals to ensure people received good quality, co-ordinated care.

Staff treated people with kindness and compassion and knew them very well. Information about people’s past lives and interests had been used to stimulate conversation and provide activity that was meaningful to people. People were listened to and their opinions valued.

People’s care needs were met by the service. Each person had a range of appropriate care plans in place and we saw evidence needs were being met. People’s likes and preferences were sought to ensure care was person-centred.

People, relatives and staff praise the management team and said they were approachable. They all felt able to raise issues or make comments which were taken on board and used to improve the service.

We found a friendly and inclusive atmosphere in the home with all staff working well together and in the best interests of people living at the home. Clear, caring values were in place and staff consistently worked to them.

The registered manager had good oversight of the home. There was an established team of managers who were all responsible for monitoring the quality of the service. There was a strong emphasis on continuous improvement of the service. People’s views and opinions were a key part of this. The owner was very involved in the home and worked in it on a daily basis.

Inspection areas


Requires improvement

Updated 10 November 2018

The service was not consistently safe.

Whilst staffing levels were appropriate in most areas, staffing levels at mealtimes and on the Margaret wing needed to be reviewed. Staff were recruited safely.

Overall risks to people�s health and safety were assessed and mitigated and staff knew the risks people posed well. People were involved making decisions about risks associated with their care

Most medicines were given consistently and safely. Improvements were needed to ensure the administration of topical medicines were always recorded.



Updated 10 November 2018

The service was effective.

Staff had the right skills and knowledge to care for people. Subject champions were in place to improve the quality of care.

People�s nutritional needs were met and there was a good choice of food available to people.

The service was compliant with the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

The service worked with other health professionals to ensure people�s healthcare needs were met.



Updated 10 November 2018

The service was caring.

People praised the staff who supported them. We saw staff treated people with kindness and compassion.

Staff knew people well and took account of people�s preferences and histories when providing care.

People were given choices and were listened to. People�s views were used to make improvements to the service.



Updated 10 November 2018

The service was responsive.

People�s care needs were assessed and a range of appropriate plans of care put in place. Staff knew people�s needs well.

People had access to a varied range of activities in the home and there were good links with the local community.

A system was in place to log, investigate and respond to complaints. Any complaints were taken seriously by the service.



Updated 10 November 2018

The service was well led.

People, relatives and staff praised the leadership in the service and said managers were approachable and listened to them.

The management team had good oversight of the service and was committed to continuous improvement.

People�s views and opinions on their care were sought and used to make improvements to the way the service operated.