Herons Lodge

Updated 2 February 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Service and service type

Herons Lodge is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Herons Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and commissioners who fund people’s placements at the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

We spent some time in the company of people and observed staff interactions with people to help us understand people's experience of the service they received. We spoke with the registered manager, the quality compliance manager, a senior support worker and 2 support workers. We reviewed in part, 4 people’s care records. Staff deployment, medicines management, staff communication and meeting records. Staff recruitment and a variety of records relating to the management of the service.

Following our site visit, we contacted 5 relatives for their feedback about the service their family member received. We spoke with a further 2 support workers. We also reviewed records the provider sent us, these included audits, action plan, the dependency tool and staff training.

Updated 2 February 2024

About the service

The service provides accommodation and personal care to people with a learning disability and or autism and people with mental health needs. The care home can accommodate 10 people in one adapted building. At the time of our inspection, there were 7 people using the service.

People's experience of the service and what we found:

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Following the last inspection, the provider had made improvements, and this had a positive impact and outcomes for people living at the service. This was confirmed by feedback from partner agencies, relatives, staff and by reviewing internal systems and procedures.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Right support: Guidance for staff of how to meet people’s individual care and support needs, including actions to mitigate known risks had been reviewed and updated. Information was detailed and reflective of people’s routines and preferences.

Safeguarding and whistleblowing procedures were regularly discussed with staff to ensure they felt confident to act upon any concerns. An internal investigation had also been completed to ensure people’s individual daily and night routines and preferences were respected and met.

People received their medicines safely. Staff responsible for administering medicines had received additional training and their competency assessed. Fire risks had been reviewed and action taken to mitigate risks. This included increasing the number of night staff available.

Right Care: Staff deployment and recruitment had been reviewed and improved upon. This improved safety and provided greater opportunities for people to lead active and fulfilling lives. Staff were kind, caring and knew people well. Relatives were positive and spoke highly of the staff.

Right Culture: The provider’s systems, processes and oversight of the service that assessed, monitored and reviewed quality and safety had been improved upon. However, further time was required for these to become fully embedded and sustained.

Staff had completed refresher training and received opportunities to discuss their work, development and training needs and further training and support was planned. Internal staff communication systems had been reviewed and improved upon.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Requires Improvement (published 22 November 2023).

Why we inspected

We carried out an unannounced focussed inspection of this service on 9 and 10 October 2023. Breaches of legal requirements were found. We issued the provider with 2 Warning Notices and gave a date in which we expected compliance to be met.

We undertook this focused inspection to check whether the Warning Notices we previously served in relation to Regulation 17 Good governance and Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) had made the required improvements and to confirm they now met legal requirements. We found the breaches in regulation had been met. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Herons Lodge on our website at www.cqc.org.uk.

Follow Up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.