Herewards House

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 requires improvement. At this assessment the rating has remained the same. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.The service was in breach of legal regulation in relation to the ways people’s medicines were managed and staff recruitment.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.There was a system in place for recording accidents and incidents.The provider told us they did not complete any formal analysis of incidents and accidents. The provider told us they discussed these with staff including any clinical issues and any changes needed for people’s support.The provider told us they did not complete any formal meetings to record and capture any lessons learned from incidents and accidents. The provider said they looked at these events individually and considered any changes needed to ensure people’s safety.Having complete records of themes, trends and lessons learned would ensure meaningful learning measuring risks, outcomes and impact of the services provided.

We discussed the process of duty of candour with the provider. Theduty of candouris a legal and professional requirement for health and social care providers in the UK to be open, honest, and transparent with people (or their families) when something goes wrong with their care or treatment, causing, or having the potential to cause, significant harm. The provider did not have a policy that set out the actions staff should take in situations where the duty of candour would apply. However, they have sent the policy after the site visit.The provider could not demonstrate they ensured the process of duty of candour was followed and recorded as per requirements of the regulation. People were supported to receive the required treatment after the injuries for example attend the hospital for further treatment. The provider sent us some further evidence how they followed this process after our request for information. While some specific steps were taken to meet the duty of candour, the information of correspondence was not always recorded. The provider did not have full oversight to ensure the specific steps taken to meet the duty of candour requirements were met and recorded.

The provider worked with people, their relatives and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when and if people would need to move between different services. People and relatives were involved in the planning and reviewing of their care and informed and supported by the registered manager and the staff team. The registered manager told us about working together with people, families and professionals where needed to ensure safety and continuity of care was a priority throughout people’s care journey. Having all the information from different parties helped the provider get to know people and provide the care they needed. The provider understood the risks to people across their care journeys and ensured information about people was available to help manage any risks in a proactive and effective way.The registered manager said, “We want [people] to be safe and secure, and that they can trust us…and establish that rapport between people and staff.”

The provider did not always share concerns quickly and appropriately. The provider did not always ensure their system in place to protect people from abuse and improper treatment was used effectively. We found some incidents where safeguarding alerts were not raised to inform the local safeguarding team for any further investigations. By failing to inform the relevant authorities of the allegation of abuse, this could place people at risk of ongoing harm or abuse. The management team informed us after the site visit they have reviewed provider’s internal reporting procedures. We considered this under the key question of well-led. People felt safe at the service and could ask staff for support or help. Relatives agreed people were safe at the service. Staff were able to explain the safeguarding process. They knew how to identify and raise incidents and who to report to. Staff were assured the management would respond to concerns.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).The provider had made DoLS referrals for people to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.For example, one person spent their time in bed and was at high risk of pressure damage. However, we did not find there was a risk assessment regarding skin integrity to ensure regular checks and preventive strategies from pressure ulcers. The person had a mattress to support skin integrity. However, they had not had their weight checked so it was unclear how the mattress setting was set correctly to ensure it did not increase the risk of pressure damage.Another person was at risk of falls and attempts to mobilise independently. There was no falls care plan in place to outline prevention strategies, supervision needs, and emergency procedures to reduce the risk of injury.A third person would get upset and distressed. They were prescribed sedative medicine as required. There was little detail recorded about specific indicators of their emotions or distress or symptoms, or how these present day-to-day. The care plan did not specify any other interventions or supportive strategies used to manage person’s distress or upset before using medicine. Having such care plan would provide a more holistic approach to person’s care and offer staff clear guidance on effective ways of support. This lack of clear guidance on risk management could put people at potential risk of receiving incorrect care or treatment.We considered this under key question of well-led.

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. The provider did not ensure appropriate legionella risk assessment and water system services were completed on a regular basis to ensure effective and safe monitoring of water the system. Provider told us fire drills were completed and staff on the shift received verbal debrief. However, the provider was unable to provide evidence of which staff had been involved in fire drills, the time these were completed, location (floor) where the fire drill was started from. There was a fuse box without a cover next to one person’s room. The provider explained the electrician had visited the service already to carry out some work. However, the fuse box was not secured to ensure it did not pose any further risk to people while work was ongoing. The handrail on the first floor bathroom was quite loose which we asked the provider to secure and ensure the risk of any incidents were reduced.

We looked around with the assistant manager to check if the service was designed to ensure it met the needs of people with dementia. The manager was engaged in the review and we identified areas of good practice to support people living with dementia, but we found some areas needed improvements. For example, light switches were not highlighted in a different colour to the walls. This could make it harder for people to see them and promote their use. Assistant manager told us different colour toilet seats were ordered. They had also ordered signs for bathrooms. We did not see that clear appropriate signs were displayed to help people orientate around the service. People sat in one big circle rather smaller circles that would encourage more socialising and conversations between people.We observed people could choose to have memory boxes outside their rooms to help them identify their bedroom. Some people chose not to have any and this was respected. People's rooms were individualised including photographs, trinkets and mementos that were unique to them. We noted there was a calm atmosphere and people were not rushed to do things. Relatives agreed it was a nice and homely place for their family members to live in.Other checks were completed to make sure equipment, facilities and technology supported the delivery of safe care.

The provider did not operate effective and robust recruitment and selection procedures to ensure they employed suitable staff. The provider did not ensure the required information according to the regulation was gathered before staff started working at the service which put people at risk of being supported by unsuitable staff. In 7 staff files we found missing information such as full employment history; evidence from previous employments related to health and social care regarding staff's conduct and verifying the reasons for leaving. For one staff, provider could not find evidence the right to work in UK check was completed before the permit expired. The provider did not ensure required checks were consistently completed at the time of recruitment. Not having all required recruitment information before staff started work, could put people at risk of being supported by unsuitable staff. The Disclosure and Barring Service (DBS) checks were completed prior to staff commencing work at the service. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. The provider did not always make sure there were enough qualified, skilled and experienced staff.

Provider needed to improve oversight for timely refreshers for training because staff were not always trained to support people with their specific needs. For example, people needed support with their conditions such as diabetes, blood sugar monitoring and insulin administration. However, staff had not had any refresher training since 2021 to ensure they maintained their skills and had up to date knowledge. People needed support with catheter care and skin integrity but there had not been any recent training provided to ensure staff were aware of the risks and mitigation in these areas of support. This put people at risk of receiving care that may not reflect their individual needs and treatment. We considered this under the key question of well-led.

The service had enough staff to provide care and support to people. The provider explained they regularly reviewed staffing numbers to ensure people were supported appropriately. They said if any extra hours were needed, they would increase staffing according to the changes of needs or any other ad hoc activities arising.Some staff noted they felt they had to rush their work when they were short staffed. However, other staff did not raise issues with staffing numbers.People and relatives were happy with staffing and their support. They said, “The staff are very friendly and there always seems to be plenty of staff around”, “The staff are good. I've never had any issues with them. There always seem to be enough staff around when I am there." and “I feel staff have the right skills for the things I need. If I ask them, they know where to refer me for information or what I need.”

The provider did not always assess or manage the risk of infection. There were dedicated domestic staff carrying out cleaning tasks throughout our visit. However, we noted some bathrooms and toilets needed further cleaning. For example, the shower room had signs of mould on the floor; the plastic shower mat also had residue of mould.Some items were left under the shower chairs. These were removed after we noted to the management team.Staff used a cleaning checklist for what items to be cleaned such as carpets, but it did not always state the timeframe. When asked for a procedure or documentation on what needed to be cleaned and when, the registered manager was not able to provide this. We also discussed the provider needed more guidance regarding deep cleaning schedule and management of it. The registered manager said they would complete those guidelines.The provider shared infection concerns with appropriate agencies when needed.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.People were prescribed ‘as required’ (PRN) medicine to manage different ailments or conditions. However, we found that PRN protocols were not in place for a number of PRN medicines prescribed. Some PRN were also given daily but without clear rationale for it or monitoring in place for effectiveness. When people had more than 1 PRN medicine to treat the same ailment, there were no protocols in place to guide staff which one to use first. When people had to have PRN medicine to support their emotional wellbeing, it was not recorded how staff supported people first before administering medicine as the last resort. Protocols for using sedatives needed more details how to support people with reassurance. The daily notes did not evidence how staff provided support and reassurance before using the sedative as a last resort. This meant people were not always supported in the least restrictive way. Medicine administration record (MAR) for topical medicine did not always note the frequency of application or which cream to use for which purpose. The registered manager did not ensure risks relating to paraffin-based creams were monitored and managed effectively. This included for 2 people who smoked. We looked for any risk assessment completed to review and mitigate any related risks however these were not completed. These were provided to us after the site visit. This meant we could not always be assured people received their medicines safely and as prescribed and this placed people at risk of harm. We discussed our concerns with the deputy manager to ensure they made amendments as needed.