Archived: The Herons

Updated 22 June 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, to look at concerns we received about the quality of the service and to provide a rating for the service under the Care Act 2014.

The inspection was prompted, in part, by notification of an incident, following which, a person died. This incident is subject to a coroner’s inquest and as a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about risk management. This inspection examined those risks.

Prior to our inspection, we reviewed information we held about the service. This included information received from local health and social care organisations and statutory notifications. A notification is information about important events, which the provider is required to send us by law, such as, allegations of abuse and serious injuries. We also contacted commissioners of the service and asked them for their views. We used this information to help us to plan the inspection.

We also used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give key information about the service, what the service does well and improvements they plan to make.

The inspection was undertaken by two inspectors. During our inspection visit, we spoke with two people who lived at the home. We also spoke with three members of care staff and the registered manager. In addition, we spoke with three health and social care professionals involved with the home.

To help us assess how people's care needs were being met we reviewed all, or part of, all three people's care records and other information, for example their risk assessments. We also looked at the medicines records of all three people, four staff recruitment files, training records and a range of other records relating to the running of the service. We carried out general observations of care and support and looked at the interactions between staff and people who used the service.

After our inspection visit, we asked the registered manager to send us a copy of various records, policies and procedures, which they did prior to this report being completed.

Updated 22 June 2018

We conducted an unannounced inspection at The Herons on 30 April 2018. The Herons is a ‘care home’. People in care homes receive accommodation and nursing or personal 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 Herons accommodates up to three people in one building. On the day of our inspection, three people were living at the home; all of these were people with support needs related to mental health conditions. This was the first time we had inspected the service since they registered with us in May 2017.

There was a registered manager in post at the time of our inspection. 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.

Risks associated with people’s behaviour were not always effectively identified, assessed or managed. There was a lack of detailed risk assessment and risk assessment processes were not robust, this placed people and staff at risk of harm. The approach to risk management was not proactive. Environmental risks were not safely managed, action had not been taken to protect people from the risk of scalding and fire and this placed people at risk of serious harm. The registered manager took swift action to address this.

There were enough staff to meet people’s needs and ensure their safety; however, due to a lack of information about physical intervention we were not assured there would be enough staff available in the event of a crisis. Safe recruitment practices were followed. There were systems and processes to minimise the risk of abuse. People received their medicines as prescribed. The environment was clean and hygienic.

People’s rights under the Mental Capacity Act (2005) were not respected at all times. This meant we were not assured that decisions made on behalf of people were in people’s best interests or the least restrictive option. Applications to lawfully deprive people of their liberty had not been made.

Care and support was not always properly planned and coordinated when people moved between different services. People were supported to attend health appointments and received support with specific health conditions. Staff had enough training to enable them to effectively meet people’s individual needs and they were provided with regular supervision and support. People were supported to have enough to eat and drink; however, more information was required to ensure risks with eating and drinking were managed safely.

People told us staff were kind and caring. Staff respected people’s privacy and treated them with dignity. People were involved in day-to-day decisions about their care and support and had access to advocacy services if they required this to help them express themselves.

Staff had a good knowledge of people’s support needs; some improvements were required to support plans to ensure people received consistent support. People had some opportunities for meaningful activity; however, these were limited. People were supported to maintain relationships with those who were important to them. There were systems in place to respond to concerns and complaints.

Systems to ensure the quality and safety of the service were not comprehensive or effective. This had resulted in areas of concern not being identified prior to our inspection and placed people at risk of harm. Timely action was not always taken in response to known issues. People and staff were given the opportunity to provide feedback and make suggestions about the running of the home.

This was the first time the service had been rated as Requires Improvement. During this inspection, we found three breaches of the Health and Social Care Act 2008 regulations. You can see what action we told the provider to take at the back of the full version of the report.