Heron Hill Care Home

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 Good. At this assessment the rating has remained Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 82 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service.

The culture was focused on facilitating mutual trust between leaders and staff as well as learning and improvement.

The service had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

The management team and staff we spoke with demonstrated a passion for the service and for what they wanted to achieve. High quality care with people achieving positive outcomes was evident throughout our inspection.

Leaders had an exceptional understanding of staff and people’s needs, their past histories and oversight of their care experiences. This knowledge and approach were central to their methods of leading an inclusive and highly effective team.One family member told us, “I feel the management do a good job at running this home. The staff are well supported as well as the residents.”

Staff told us they were fully supported by the management team and were encouraged to question practices and suggest new ideas or initiatives to help continually improve their practice. One staff member told us they had made suggestions about the Herbert Protocol (a national scheme wherecare staff compile vital information about missing adults) and they had been given paid time to develop training and deliver it to staff.

The management team understood CQC requirements. They kept up to date with all relevant changes and communicated these effectively to their team.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The registered manager told us, “Whistleblowing is discussed at every meeting, and we have a whistleblowing policy in place. We encourage staff to see the importance so we can make things better.”

Staff felt able to report concerns in one-to-one meetings and the registered manager had an open-door policy. One staff member told us, “I can report [any issues] to the line manager and I would go to the regional manager if needed. We have all read the whistleblowing policy and there is whistleblowing information displayed in communal areas.”

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager told us, “We have a lot of staff from overseas and we endeavour to accommodate annual leave requests for when they would like to return home although, this is more difficult during school holidays. We facilitate our staff prayer time and allow time off to observe religious celebrations. We also organise religious events with our staff.”

For the most part, the service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was a range of quality monitoring and auditing in place to ensure the premises and care home environments were safe, and that people received safe and high-quality care.There were robust arrangements in place for the availability, integrity and confidentiality of data. The service submitted the appropriate notifications to CQC where required to do so.

However,improvements were required to auditing of medicines as they did not identify issues we found with out-of-date medication, or lack of required information in people’s medicines care plans and administration records, and with timings around paracetamol administration. When we told the registered manager about this, they put a plan in place to ensure auditing procedures were more effective.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Effective processes were in place and embedded in the service to ensure partnership working with people, relatives, health professionals were maintained and to improve people's experiences, health, and wellbeing. The registered manager told us, “We work very well with the GP practice and other health professionals and the pharmacist visits weekly.”

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Discussions with leaders and staff demonstrated a drive and passion for continuous improvement, and to seek collaborative ways to enhance people’s care and support. Some staff had been designated ‘champions’ in their area of expertise such as safeguarding or infection prevention and control.

Leaders, managers and staff strived for excellence through accreditation schemes to enhance outcomes for people and through learning and development. The home had achieved accreditation for their dementia care and end-of-life care. Accreditation schemes are formal processes where external bodies assess and certify that a care provider meets specific standards, demonstrating a commitment to quality and continuous improvement.

The management team had overseen an exceptional training programme which ensured their staff could provide the best care possible. Staff had been able to complete NVQs in health and social care, and some staff had completed Care Home Assistant Practitioner (CHAP) courses and secured CHAP positions in the home. One staff member had received full pay to embark on training which started at NVQ level 3, then a level 5 healthcare assistant practitioner programme before going on to complete a nursing top-up programme to qualify as a nurse. This staff member had become an integral member of the leadership team and was training in-house staff as well as contributing to the learning of others in the local healthcare network.

The service also provided placements for trainee nurses and paramedics from local universities in which care home staff could contribute to the learning of future health care professionals.

The management team attended regional meetings with other care homes within the company to discuss ideas collected from residents about how to improve their care. Regional management meetings also took place where lessons learnt were discussed. The registered manager attended local manager networks to learn about changes to best practice.

The service had expressed an interest in contributing to national research such as recruitment and retention of younger staff in the social care sector; and on activities in care homes.