Heron Hill Care Home

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 Good.

At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was a culture of learning from incidents. Staff knew how to report safety incidents, which were investigated by the management team and immediate actions were taken, where required. One staff member told us, “When somebody has had a fall and their falls sensor is triggered, we go and assess the person, press their emergency buzzer, call for a nurse who checks them over, and we call for an ambulance, if necessary. We record what has happened and undertake regular observations.” Another staff member told us, “If I see somebody has got a bruise, for example, I will make sure I contact the nurse, and I record what I have seen.”

The service analysed data from safety events, such as falls and behavioural incidents. Issues identified from this analysis, such as ensuring records were completed effectively, were then shared with staff in team or one-to-one meetings.

The service worked with people 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 people moved between different services.

People’s care plans contained their pre-admission assessments which included person centred information about their previous care experience and the desired outcomes of their care at Heron Hill Care Home. This demonstrated a clear focus on continuity of care for people.

The service ensured assessments from specialist health professionals, when they were actively involved, were included in people’s care plans. Staff used these assessments to ensure people received the right support. One professional visiting the service told us, “Following [people’s] assessments, I will send through a full care plan for the management of the [health condition] and I find this is followed well in patients when I review the progression.”

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

The service investigated safeguarding incidents and shared concerns quickly and appropriately with the relevant authorities. One professional visiting the service told us, “The care home referred [an alleged incident] to us. They have been very responsive and generally liaise well with the safeguarding team.”

Staff had received safeguarding training and knew how to identify and report abuse. One staff member told us, “We have a safeguarding champion. If I see something wrong, I will report to the clinical lead. The managers are serious about safeguarding and always follow safeguarding procedures.” Safeguarding information and how to raise concerns was available to people, visitors and staff.

The service analysed data from safeguarding incidents to ensure all actions had been taken, where required, to ensure people were safeguarded from abuse.

Where people needed to be deprived of their liberty to keep them safe, the service ensured a deprivation of liberty safeguard (DoLS) was applied for through the relevant local authority. A log was in place to ensure staff could check the status of these applications.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Where people had known risks such as with swallowing, mobility, or their behaviour, we observed staff supporting them safely and delivering care in line with their risk assessments. Specialist equipment was used where required. One person told us, “I need a lot of help to move around, and the staff are always there to help me. I have to be moved by a hoist, and I always feel confident with the staff who use it.”

Risk assessments contained enough detail to guide staff how to manage risks and escalate concerns, when required. One staff member told us, “Some residents [have behavioural needs]. I know how to talk to the residents. I check if they need support with anything and try to reassure people and give them time. I remain calm, check the environment, and ensure other residents are safe.”

When we discussed with the management team the risks for a person who smoked and who also used emollient creams, they updated their risk assessment straight away.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There were effective systems to ensure the environment was kept safe. Environmental risk assessments were in place such as fire safety, gas safety and water safety. These were up-to-date and where issues were identified, these had been addressed or there was a plan in place to address them. Regular audits took place to monitor the safety of the premises and equipment. One relative told us, “This home provides a great, safe environment for my [person].”

Routine testing took place for fire alarms and evacuation procedures. When the fire alarm was unexpectedly activated while we were on-site, staff followed fire safety procedures effectively.

People were able to move safely around the environment. There were grab rails and specialist equipment available to support people who needed these. People were provided with specialist beds, hoists, and other equipment. There were coded doors to help restrict access to non-communal areas to keep people safe. People had Personal Emergency Evacuation Plans (PEEPs) in place to guide staff how to evacuate people safely in the event of an emergency.

When we discussed with the management team an issue with exposed pipes in 1 communal bathroom, they put a plan in place straight away to cover them.

The service made sure there were enough safely recruited, qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff felt they delivered safe care and had received the required induction and training to undertake their roles safely. One staff member told us, “I have done all my training and, as part of my role, I check that staff have completed their training too. Everybody is up to date.” Another staff member told us, “When I started, I had a DBS and shadowed for a while. I had a supportive mentor, but I was able to shadow other staff on different floors. I’ve had both face-to-face training and e-learning.”

There were enough staff on duty to meet people's needs. The service used a dependency tool to calculate the numbers of staff they needed.

Team meetings, one-to-one meetings and daily handovers were in place to support staff to provide safe care to people.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Housekeeping staff were available, and the service was observed to be clean and tidy throughout. One person told us, “I have a nice room which is mine and is kept clean for me.”

Staff were provided with personal protective equipment (PPE) and were observed wearing and removing this appropriately. One staff member told us, “We are given PPE which we properly dispose of in the right bags. We follow safe hand hygiene practices.”

There were handwashing facilities throughout the building and also access to hand gel. There were clear instructions above every sink on how to wash hands properly.

Staff had received training to support with minimising the risk of infection and information about safe infection prevention and control practices was displayed throughout the care home. An up-to-date infection prevention and control policy was in place.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Medicines were stored securely and staff monitored temperatures of areas used to store medicines, to ensure they were kept within the recommended range. Medicines were managed by staff who had received training and had their competency assessed.

There was a system in place for staff to record the application of topical medicines such as creams and we found that these were completed.

Although care plans and medicine administration records were in place and contained information that staff would need to support someone with their medicines, we found examples of the information not always being up to date. After the inspection we were told that a process had been put in place to review care plans to ensure they were accurate.

For three people who had their medicines crushed to be given covertly or due to swallowing difficulties, we found there was not always the appropriate paperwork in place from a healthcare professional that would ensure that this was done safely. Where there were instructions in place staff told us they did not always give the medicines in this way. After the inspection we were told that the service had contacted the GP for all people receiving medicines in this way to ensure that paperwork was updated, and staff were aware of any changes.

We found for medicines that need to be given at a prescribed time for Parkinson’s then staff did administer these at the time instructed. However, for two people taking paracetamol containing medicines that require a four-hour gap between doses we saw that this was not always followed, and people received doses of medicines too soon. After the inspection the provider told us staff were being retrained and systems improved to prevent this happening again.