Herons Park Nursing 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 requires improvement. At this assessment the rating has changed to 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 provider 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.

The registered manager encouraged an open culture of continuous learning. Accidents and incidents were recorded accurately, and action was taken to minimise potential future risks.The provider’s systems ensured learning was embedded quickly, and actions were taken without delay. Daily meetings took place to discuss people's needs. Any changes or incidents which may have occurred were discussed to ensure all staff were up to date. The registered manager was receptive to our feedback and took action where necessary to improve safety of people and quality of care provided. The registered manager understood their responsibilities under the duty of candour to be open and transparent when things went wrong.

The provider 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.

Managers and staff worked closely with health and social care professionals to ensure people received the care and support they needed. The management team undertook thorough pre-admission assessments, and considered the information gained alongside any available social worker assessments and medical information, to ensure the service could meet people’s needs prior to admission. People and their relatives told us they had good access to GP’s and other health professionals, and care plans included relevant assessments and clinical guidance.

Staff knew and demonstrated a good understanding of people's needs. Health and social care professionals were contacted in a timely manner when required to offer support and guidance. We received positive feedback from 2 healthcare professionals.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe living at Herons Park Nursing Home. A person told us, “I have no reason not to be safe, I’m very happy here.” Another person told us, “It’s safe. Oh yes, it’s the people who look after me make me feel that way.”

Concerns were escalated promptly and in line with established procedures. Staff had completed the relevant training and demonstrated a clear understanding of their safeguarding responsibilities. People and relatives told us they felt safe and confident with the care provided.

There were safeguarding procedures in place. The management team understood their responsibilities regarding any action needed to protect people from harm. The necessary internal documentation was completed including accident and incident logs and body maps. The registered manager ensured referrals and notifications were made to both the local authority and the Care Quality Commission in a timely manner.

The provider 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.

People told us they felt safe because staff always followed their care plans and risk assessments. A person told us, “I’ve not had any falls, there’s always 2 people (staff) with me when I get out of bed.”

Individual and environmental risks were identified and managed. Care plans outlined how best to mitigate each risk and guided staff how to support people to remain safe. These were reviewed regularly to ensure the information remained accurate and complete.

We saw staff transferring people safely throughout the day. This included using a hoist. Staff spoke with people throughout and were gentle and reassuring when moving people between wheelchairs and armchairs.

Where people were at risk of their skin breaking down, pressure relieving mattresses were provided. We checked several and found these were set in line with the person’s current weight. This helped ensure the mattress was most effective to support people’s pressure care needs.

During our inspection we reported to the registered manager 1 person’s monitoring arrangements were insufficient. Following our on-site visit the registered manager consulted healthcare professionals and introduced new measures including new monitoring equipment, to ensure the person’s safety.

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.

Equipment used to support people, such as hoists, were serviced and inspected in line with regulations. We saw equipment was appropriately maintained and clearly labelled.
Fire alarms were tested weekly, and evacuation procedures were clearly documented. Fire safety equipment was in place and regularly checked. Water checks and water tests took place regularly to prevent growth of harmful bacteria.

However, some environmental issues were observed on the first day of our visit. For example, we saw cables in communal area in line of people walking and some reclining chairs had frayed cables. This posed a risk of trips and falls and potential electrocution. We brought this to the registered manager’s attention who addressed our concerns by the end of our visit.

The provider made sure there were enough 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.

We received mostly positive feedback about staffing levels from people, their relatives and staff. A person told us, “There always seems enough staff.” Another person said, “I’ve never had to use my call bell because they are always around.” Another person’s relative told us, “I come 2-3 times a week there’s always staff around.”

Staffing levels were monitored to ensure people received safe and timely care. During our visit we saw a person was distressed and anxious due to their individual health needs; staff supported them promptly and sensitively.

Staff went through an established induction, shadowing and training regime prior to working alone. Training was completed through a mixture of on-line and face to face training and refresher training was undertaken by staff to help ensure their retained their knowledge and learning. Staff worked collaboratively to provide safe, person-centred care. They told us they received regular supervisions and one-to-one support and spoke positively about the support they received from management.

Staff were recruited through robust processes which included them providing references, a full work history, their fitness for the role and their right to work in the UK.

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

The home was mainly clean, and staff worked throughout the day to ensure all areas remained tidy. Staff had been trained in infection prevention and control. Personal protective equipment (PPE), such as gloves and aprons, was discreetly stored around the home and staff used these when required and washed their hands immediately after use.

Cleaning schedules were designed to ensure all areas of the home and equipment was regularly cleaned. Audits were completed to ensure compliance with the procedures and policies of the home.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People and where appropriate their relatives told us they were informed about changes in people’s medicines. One person’s relative told us, “They tell me if their medicine changes.”

Medicines were stored safely. Medication rooms were temperature controlled and records of temperature checks showed rooms and medicine fridges were maintained at suitable temperatures. Records showed people had their medicines administered on time, as prescribed.

We reviewed medicines administration records (MAR) and found these had been completed correctly, with no unexplained gaps. Clear processes were in place for the safe storage and disposal of medicines. Regular audits were carried out to monitor practice and ensure procedures were being consistently followed, with any issues identified acted upon.

Some people were prescribed medicines on an ‘as required’ basis. Personalised protocols gave staff guidance about how each person would express the need for these medicines and included specific strategies staff could deploy to support the person prior to administering medicines.