Herondale

On this page

• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to the management of medicines and safe care and treatment.
 

This service scored 38 (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 proactive and positive culture of safety based on openness and honesty. Lessons were not learnt to continually identify and embed good practice.

The service did not always demonstrate learning, and improvements through analysing incidents when things went wrong. Where improvements had been made as a result of things going wrong, the improvements and action taken had not always been well documented. For example, a person who required staff supervision at all times was able to leave the service via the front door without staff’s knowledge which had led to them being reported missing. Action was taken to reduce the risk of this happening again, including fitting a door sensor and new keypad entry codes. The incident was discussed with staff in a team meeting. However, the person’s care plan had not been updated to reflect the incident or the new measures staff needed to follow. Furthermore, the person did not have a risk assessment in place if they chose to leave the service unnoticed by staff. This put the person at risk of staff not knowing how to safely support the person.

The approach of incident reviews was inconsistent. We read an incident report where 1 person had been injured. The person was given first aid, and the incident was reported as a safeguarding referral to the Local Authority. However, the incident report stated no first aid was given and a box ticked to indicate it was not reported as a safeguarding referral. The manager did not formally investigate the incident and when asked the manager said, “I talked about it with the person and I knew what had happened, there is little I can do to prevent it, I did not do a formal investigation.” This meant the manager missed the opportunity to consider what could be learnt and any changes needed to prevent recurrence.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

We reviewed the care plan of a person who was under a Deprivation of Liberty Safeguard authorisation. This meant the person needed supervision at all times. The care plan referenced an incident where the person had previously left hospital after being discharged during the night. There was no risk assessment in place to support safe discharge from hospital.

Staff supported people with medical appointments in order for their mental and physical health care to be monitored, However, care plans and risk assessments were not always updated in line with changes from guidance and advice given at the appointments.

Staff knew people well and liaised with healthcare professionals as and when required on behalf of the people they supported.
 

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

One person’s care plan stated they made false allegations. This was not an appropriate statement and implied there was an assumption the person was not being truthful. This increased the risk of staff not acting on concerns reported by the person. There were no guidelines within the care plan to inform staff how to support when allegations were made.

There was an inconsistent approach to safeguarding. Systems were in place for reporting incidents or events which needed a safeguarding referral being made. However, investigation and lesson learnt reviews were not always documented. Risk assessments were not always put in place to safeguard people. For example, a person had 2 falls within 3 months while being supported to access the community. A risk assessment to prevent falls and inform staff what action to take if the person falls was not put in place after either incident.

The manager was using team meetings to introduce a culture of reflective practice which included discussing with staff what worked well and what did not. This was not fully embedded, for example an incident happened in November 2025, there was no team meeting with staff in December, and it was not added to the agenda for January’s 2026 team meeting. This meant there was a missed opportunity for learning, and the safeguarding incident was not reviewed as a team. A similar incident happened again in May 2026, which was not discussed at a team meeting.

Care plans did not have enough information to inform staff how to safely support people. For example, we identified inconsistent information around blood sugar testing for 1 person with type 2 diabetes. Furthermore, testing was not being done in line with the person’s care plan. We also identified key information missing from care plans such as formal mental health diagnoses and how staff should support the person to maintain good mental health. [JE3.1]This put people at risk of staff not understanding their care and support and their needs not being met.

The manager was able to explain the safeguarding processes. The safeguarding policy detailing how staff should report concerns was displayed on the office wall.

People told us they felt safe and would report concerns to the senior support worker.

The provider did not work well with people to understand and manage risks. The provider failed to have effective and robust systems in place to review people’s care plans ensuring consistency between care planning and risk assessing.

Processes were not effective in assessing risks. We identified multiple risk assessments missing for people with known risks such as mental health ill health, diabetes, stroke, depression, personal care, allegations, missing persons and falls. This put people at risk of avoidable harm.

Where risk assessments were in place they did not always capture information in the best way and information did not triangulate between assessments. For example, one person had a risk assessment for consuming condiments in an unsafe way. Within this risk assessment it stated they put cooking oil in their hair. The known risk of putting cooking oil in their hair was not included in the person’s smoking risk assessment, which put them at risk of setting fire to themselves whilst smoking. We shared our concerns related to risk assessments with the provider; they assured us they would make improvements.

Additionally, the provider failed to identify via audits that risk assessments had not been put in place or lacked sufficient information to mitigate risks to people.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Audits of the environment were undertaken within the service. These audits include walking around the environment checking and noting concerns. We found these audits were not being completed effectively. For example, the audit failed to identify the risk of an electrical extension lead under a handbasin in the kitchen. There were a countertop fridge and a fan plugged in the extension lead. There was a risk water could be spilt directly on the extension lead increasing risks of electrical shock or fire. We bought this to the manager’s attention who took remedial action.

There had been an improvement in escalating repairs since our last assessment, and where repairs had not been completed, they had been carried over to the next month’s audit.

The provider did not always ensure staff received the appropriate training to safely meet the identified needs of people receiving a service. They did not always make sure staff received consistent development through lesson learnt reviews.

One person’s care plan stated, ‘staff must receive training in recognising symptoms and supporting people with paranoid schizophrenia’. We reviewed staff training and staff had not received this training, additionally staff had not received mental health awareness training.

Staff received supervision and took part in team meetings. The manager told us how these were good forums for reflective practice with staff to inform them of lessons learnt, however this was not always consistent and there were missed opportunities to share information with staff.

We checked two staff recruitment files and found both files had gaps in people’s employment history, which is a requirement of Schedule 3 of Regulation 19 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

At our last assessment we found there were insufficient numbers of staffing. Whilst the staffing number had remained the same the number of people using the service had decreased, therefore at this assessment we found there was enough staffing.

Two people told us they accessed the community independently so did not rely on staff being available to support. We observed staff offering people choices and supporting them to access the community on the days of assessment.

Although care plans lacked detail about people’s history, their life story and current interests, staff knowing people well. We observed staff interacting with people through meaningful task such as meal preparation. Staff spoke to people with dignity and respect and people told us staff were kind to them.

The provider did not assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The provider failed to ensure systems for all areas of infection prevention and control (IPC) were effective. For example, there was no risk assessment in place for finger lancing and no system in place to ensure lancing needles were safely removed from the blood glucose device and disposed of after use. During our assessment we found a needle left in a lancing pen. We checked the provider's records of when the last blood glucose test was completed and found it was 23 days earlier. The provider had no systems in place to identify if the lancing needle had been in the device since the last recorded test. This put people and staff at risk of infection due to poor IPC measures.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

We found concerns with the documentation for people’s medicines. For example, we found transcribing of medicines on one person’s medication administration record [MAR] was not in line with the provider’s medicine policy. The provider’s policy stated where hand transcribing is done, it must be signed and dated by 2 members of staff confirming the information was correct. We found transcribing entries were not signed. Additionally, when we asked if the staff member transcribing had seen the prescription to check this corresponded with medication packaging, we were told, they had never seen the prescription. This meant there was a risk staff would not identify any pharmacy errors with the medicine and increasing risks to people.

We also found unauthorised changing of medication instructions on another person’s medication administration record. Cream had been prescribed to be applied 4 times a day, and this was printed on the MAR chart by the pharmacy. Underneath the printed text in big handwritten letters, highlighted in yellow it stated, ‘wash only’ and only 08:00 was highlighted on the MAR chart for Monday to Friday with Saturdays and Sundays crossed out. This instructed staff to apply the cream once a day as a soap rather than the prescribed 4 times a day and for its intended use. As a result, the person was not given then medicine in line with their prescription.

There was inconsistent information in the medicines folder. We found a letter stating 1 person should be given their medicines covertly. When we discussed this with staff, we were told this was out of date information and the person no longer had their medication covertly.

There was poor documentation for as and when medicines [PRN medicines]. We found times to offer PRN medicines had been prescribed on MAR charts and staff had been signing not required when medicine was not needed at the dictated times. This was restrictive and institutional practice because it did not allow people the flexibility needed with PRN. For example, if staff have already signed that the person does not need their paracetamol through the day there was then no room on the MAR chart to sign if the person needed the PRN at night.