Herons Park Nursing 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 requires improvement. At this assessment the rating has changed to 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 71 (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 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.

The registered manager and all staff had a good understanding of their roles and shared a commitment to providing person centred care and treating and valuing people as individuals. The provider and staff worked with people and their relatives to build a culture which focused on providing person centred and responsive care. A range of policies were in place to guide staff.

Staff spoke positively about working as part of a supportive team and shared a clear commitment to improving people’s lives. A member of staff told us, “I absolutely feel supported by [registered manager] and [staff], their door is always open, if there is a problem they listen and help.”

People and relatives also described the home as welcoming and friendly. One person told us, “I don’t think there’s anything they could do better.” Another person said, “It’s a good home, I would recommend it.”

The provider had 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 did so with integrity, openness and honesty.

People, relatives and staff were complimentary of the registered manager. A person told us, “The manager has been excellent so far.” Another person said, “I know the manager [registered manager] they are very good. if I want anything they will arrange it, they are very good like that.”

Team meetings provided staff the opportunity to understand any planned changes within the home, discussed best practice and shared what was working well and any challenges.

The leadership of the home ensured people experienced high quality care which was evidence based from staff which were calm, confident and competent to carry out their role, in a kind and caring manner.

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

Staff felt confident raising concerns and said they were listened to without fear of negative consequences. They described an open‑door approach from managers and said issues were addressed promptly.

The provider had processes which supported people, relatives, and staff to speak up about any concerns within the organisation. The registered manager told us they welcomed people, staff and visitors to raise concerns with them. Staff understood how to report concerns and how to escalate if required.

A whistleblowing policy was in place and accessible to all staff, supporting transparency and accountability within the service.

The provider 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 management team actively sought and considered staff feedback through a range of methods, including surveys and team meetings. This helped leaders understand staff experiences and promote a positive and inclusive working environment. A member of staff told us, “We have senior and nurses meeting every 2-3 months. I can raise any concerns, but I don’t have to wait for the meeting if I had any concerns, (registered manager’s) door is always open.”

The staff team was made up of individuals from a range of diverse backgrounds. Staff told us they felt comfortable and welcomed within the service, and no concerns were raised in relation to equality, diversity or inclusion. Staff consistently described a positive culture where diversity was recognised and respected.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

A range of audits and quality assurance systems were in place and used to monitor the quality of care. However, these were not always effective in identifying all the issues found during the inspection, including risks related to health and safety.Although we saw no impact to people, and although the management team were prompt in putting corrective actions in place, the shortfalls in records did indicate some improvements with monitoring and oversight was required. The registered manager acknowledged these findings and demonstrated they had already begun to review and strengthen governance systems to ensure greater oversight and reduce the risk of similar issues being missed in future.

Visiting professionals told us concerns were shared promptly, which supported effective partnership working and helped to ensure safe outcomes for people.

The provider 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.

We were provided with positive feedback on the quality of care provided by the service. A healthcare professional told us, “We are particularly impressed with their dementia care. Where many other homes decide to serve notice on "challenging " or " tricky " residents the staff at The Herons persevere and find ways to manage them.”

Leaders worked closely with health professionals and services to ensure people received safe and effective care. This partnership working supported timely communication, shared decision-making and continuity of care.

The service worked well with external agencies such as the GP practice, district nurses, tissue viability nurses and the dieticians. This helped ensure people received the support they needed when they needed it.

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

There were systems and processes in place to ensure lessons were learnt from incidents accidents or safeguarding concerns. These were reviewed to help identify any themes and trends which may influence a change to the practise within the home. Staff training records were regularly reviewed to ensure staff were equipped with the up-to-date knowledge and skills to provide a good level of care and support.

The provider remained open and transparent throughout the inspection process, and both the registered manager and leadership team showed a strong willingness to respond to and learn from any concerns identified.

The provider also worked collaboratively with partners. This supported ongoing learning and helped ensure care remained responsive and tailored to people’s individual needs.