Herondale

On this page

• 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of the legal regulation in relation to good governance at the service.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, inclusion, and engagement. The provider did not lead by example and monitor the service against their values or work effectively with the registered manager, people, their representatives and staff to build a culture that focused on enabling people to live their lives to the fullest.

The provider gave little direction to the team on building a positive culture with collaboration and co-production. Action plans lacked the involvement of staff and people who used the service and their families. A staff member told us, “We were told to read the CQC report but there were no meetings with us about it. We then got a cleaning schedule given.” The support offered from external partners was not utilised to effect a change in practice and culture. Despite some improvements the registered manager had made to staff practices, the staff team were not always working together effectively to ensure a change in culture could be embedded.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders with responsibility for Herondale had not provided clear strong, credible leadership. There was a disconnect between the provider corporate team and day-to-day management practice and care delivery. Senior leaders were supporting the registered manager and staff team. However, this support was not effective as they did not monitor that the service was making the necessary improvements within the appropriate timescales or to amend their improvement plans if required for the quality of the service to improve. The provider lacked responsiveness increasing the risk of delaying improvements to the quality and safety of care delivered to people using the service.

The registered manager was highly visible, compassionate, approachable and led by example. People told us, “I prefer [registered manager] to help me in the shower,” “I like being with [registered manager] when they are here,” and “[Registered manager] takes me to my hospital visits, they make it okay for me.” A staff member told us, “[Registered manager] is a very good manager; you could not get anyone better, with good values and caring but they [provider] could help a bit more.”

The provider did not always promote staff empowerment to drive improvement. This was evidenced by the lack of staff involvement in supporting change to take place. However, staff told us they were confident to raise concerns with the registered manager and that their voices would be heard without fear of detriment. Concerns were addressed by the registered manager sensitively and confidentially.

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.

The provider valued diversity in their workforce. However, they did not always take steps to ensure staff were representative of the population of people using the service, for example, there were no male staff members currently employed, so people did not have a choice of gender of staff to provide their care.

Staff members’ protected characteristics were considered to ensure their rights under the Equality Act 2010 did not have a negative impact on their wellbeing. The provider made reasonable adjustments to support disabled staff to carry out their roles and responsibilities. Staff had undertaken training in equality and diversity to support wider awareness in their role. A process was in place to act on staff feedback about their role and responsibilities, and to promote fairness amongst the staff team.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Whilst some improvements had been made since the last assessment, including infection prevention and control processes and involving people and their families in their care arrangements, we found further concerns at the service which had not been addressed. The provider did not have effective management systems in place and failed to identify the significant concerns highlighted within this and the previous assessment.

Risk assessments were not completed for all areas of risk relating to people and the premises to ensure people were kept safe. Fire extinguishers had been placed in the service for fire safety, with some training for staff in how to use them. People’s personal evacuation plans were in place. However, sufficient oversight of fire evacuation procedures at night had not been undertaken to ensure 1 staff member who slept in at night could evacuate people from the service safely.

The systems to assess, monitor and mitigate risks relating to the safety to people and staff had not significantly improved. There continued to be a lack of oversight of the service as the provider and registered manager did not fully monitor and identify where improvements were needed. There were additional concerns found with the staffing levels at the service which denied people of their rights and freedoms and did not protect staff. For example, medicines management, fire evacuation procedures at night, staff availability at night and people not being able to go out due to lack of staff available.

Some care plans had been improved in content and updated. However, not all care plans reflected people’s current needs and associated risks to their health and safety, including smoking, restrictions on going out of the building alone, and the use of paraffin-based emollients. 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.The bathroom facilities had not been improved since the last assessment. This meant that people had been without suitable and comfortable bathing facilities for a further 9 months which was unacceptable.

Governance processes were still not effective in the oversight of the service. Whilst the provider sent us an action plan of improvements they had made, systems to ensure compliance with legislation and the providers internal governance arrangements were not comprehensive. 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. 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.

The provider had not investigated or utilised relevant or mandatory quality frameworks, recognised standards, best practices, or equivalents to improve equity in experience and outcomes for people using the service. The lack of robust systems to assess, monitor and mitigate risks led to continued concerns in areas such as staffing, fire safety, medicines management and access to basic facilities, which affected people’s dignity, rights and freedoms. Inconsistent care planning and poor risk assessment practices further compromised the provider’s ability to protect people from the risk of harm and ensure their well-being.

The provider was introducing an electronic care planning system. The registered manager told us recording, viewing and updating information would be easier and more efficient. Training for staff in using the system was underway. There were robust plans in place for business continuity in case of emergency or natural disasters, such as adverse weather events and this was up to date.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. A local authority had completed an assessment of the care provided at Herondale in January 2025. They reported that despite their input, advice and support, there was not enough improvement made for assurances that people received safe care and support. The fire service raised some concerns during their recent inspection about fire safety procedures for people who smoked at the service which had been actioned.The provider’s failure to work effectively with partners and respond to safety concerns placed people at avoidable risk and compromised the coordination of their care.

People who could, accessed the community independently and had particular places they liked to go. The provider was not proactive in looking at opportunities for people to integrate within the wider community with the intention of improving people’s outcomes.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Due to the failings identified at this and the last assessment, leaders were still reactively responding to concerns raised by us and external stakeholders rather than being proactive in the development of the service. Whilst improvement work had started, leaders were not yet in a position to demonstrate the longer-term outcomes and benefits for people and staff. The creation of a number of action and development plans were difficult to manage, evaluate and measure outcomes and the impact. This meant leaders could not demonstrate improvements were working and learning embedded.