Heron Court 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 inspection we rated this question good, this rating remains unchanged. Provider had systems in places to manage risks to the quality of the service and protect people from the risk of abuse and neglect. However, the systems were not always implemented effectively and as a result, not all risks were assessed adequately. Following our feedback, the provider took immediate action to mitigate the risks we were concerned about. Staff managed medicines and treatments safely and met people’s needs. Provider ensured there was enough qualified and skilled staff that worked together effectively to support people’s individual needs. Staff supported people in a safe way that enabled them to do things that mattered to them.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We spoke with 16 relatives and 2 people about their experience at Heron Court. We received positive feedback about people’s experience transitioning into the service. Family members confirmed they were involved in this process and felt assured staff gathered the relevant information about people prior to them moving into the service. Referrals to relevant professionals were made. One relative said, "They are very open with me. When [my relative] came in, I filled in a form about what [my relative] life was like. They phone me up about things. I see all the care plans as I was in a meeting with the Social Worker, so I know as much as they do". Another relative said, "Initially they discussed [my relative's needs and asked all about [the relative] as a person. The home always ring if they need to ask me anything or to update me on anything. The care [my relative] gets is perfect.”

Leaders followed the provider’s policy and process when admitting people into the service. This included a pre-admission assessment which involved the person and their families. Leaders had positive working relationships with partners which helped to ensure safe transitions into the service. The digital system used for care planning and risk assessment allowed for information to be pulled quickly which could be shared when people were discharged, or admitted into hospital. This ensured continuity of care. Leaders were aware of key risks associated with transitions and were able to explain how they monitor and mitigate these risks. This included examples of raising safeguarding concerns, or ensuring referrals were made to relevant professionals. The provider had a specialist placement team which worked with the management to ensure placements into the Kingfisher unit were made safely. Leaders were confident in challenging where information was lacking, or information suggested an admission may not be safe. Staff explained information is shared with them prior to a new admission and they have chance to read people’s care plans. Staff shared they have opportunities to input into people’s care plans from their experiences with supporting people and as they get to know them. Nurses were informed of people’s clinical needs through regular clinical risk meetings.

Partner agencies spoke positively about the service and safe systems of care. One of the professionals we spoke to about the service told us that the service is responsive and good to work with.

The provider had policies and processes about safety that aligned with other key partners who were involved in people’s care journey to enable shared learning and drive improvement.

People and the relatives told us they felt safe at the service and had staff members they could talk to if they did not feel safe. All of the relatives said they had no concerns about their loved ones's safety. The comments included, "I most certainly do [feel my relative is safe]. [My relative] is shown nothing but love, dignity and respect. They [care staff] are such lovely people", "[My relative] is one million percent safe there. The staff are so good".

Care staff understood their responsibilities in relation to safeguarding. They felt safeguarding was paramount and knew how to report safeguarding concerns. Leaders explained they had identified a need for further training on Mental Capacity Act (MCA) with the staff, and had implemented this to increase staff confidence. Staff confirmed they had received safeguarding training. Staff understood and worked in line with the MCA and DoLS. When partner agencies expressed concerns in regards to a safeguarding concern identified at the home, the leaders worked collaboratively with the partners to mitigate potential risks.

We carried out a Short Observational Framework for Inspections (SOFI) to help us understand the experiences of people who may not be able to verbally express this to us. The SOFI showed us that people were relaxed in the presence of staff and felt able to ask them for support. Staff took the time to meet people’s emotional needs. Safeguarding information was visible around the service, this helped people to know how to report concerns. Staff were observed to have kind and caring approaches when supporting people. People seemed comfortable in the presence of staff and we observed them taking part in activities together. The atmosphere within the home was calm and relaxed.

The provider had safeguarding systems, processes to ensure people’s human rights were upheld and they are protected from discrimination. However, not all risks were adequately assessed and mitigated prior to our assessment. The provider worked with partners in a collaborative way to address the concern. A ‘lesson learned’ approach was implemented to ensure that learning and actions were shared with staff teams following a safeguarding. This helped to mitigate risk and improve safety. A safeguarding newsletter had been created which was available for people and staff to take copies of. This covered themes and provided examples of actions being taken to improve the service.

Overall, people and relatives felt staff understood people’s needs well and supported them safely. We received some feedback that improvements could be made about the services’ approach to positive risk taking and they were discussing this with the service.

Leaders understood the importance of involving people and their families in the risk assessment process. They explained their input was valuable in ensuring they had a good understanding of people’s needs, preferences and routines. Leaders reflected on positive risk taking and provided some examples where they had done so, for example reducing the level of one to one support people required. Staff knew people well. Staff understood how to support people and their identified risks safely. This included how to respond when people communicated signs of distress. Staff gave examples of supporting people to feel reassured. This included putting people’s favourite music on, or moving them to quieter areas.

The SOFI showed us that staff supported people’s risks in line with the guidance within their care plans. Staff had a good understanding of people’s needs. Our informal observations showed staff understood how to support people and their known risks and follow guidance within their care plans. For example when people required support to eat their meal at lunch. People were observed to have equipment they needed to keep safe.

There were systems and process in place to ensure that people had appropriate risk assessments in place. Risk assessments about care were person-centred, proportionate, and regularly reviewed with the person, where possible. There was a restrain policy in place . People’s care plans reflected any foreseeable risks that may need restrictions.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and relatives felt there were enough staff to keep people safe. Overall, we received positive feedback about staff’s kind and caring approach. One relative said, “I have 100% confidence in them in terms of the care they provide.”

Leaders told us and the staff confirmed there was enough adequately trained staff to provide high quality care to people. Leaders explained staffing levels were based on the dependency levels of people using the service. Leaders felt supported by the provider in ensuring staffing levels were safe. One staff member said, “We have a good balance of staff.” Leaders explained that they review training routinely, and will listen to staff feedback to ensure the training is meeting their needs. Leaders provided support in the way of regular supervisions and appraisals. Staff felt they worked well as a team. Staff reported they felt well trained in their roles and received regular support in the way of supervisions and appraisals.

The SOFI showed us that staff were visible and available to support people’s requests for help and take the time to sit with people, attend to their emotional wellbeing and take part in activities. Staff worked well as a team to make sure tasks were completed, but also ensured they interacted with people in an appropriate way. Our informal observations showed there were enough staff to meet the needs of people using the service. Communal lounges were supervised at all times. People did not have to wait for their support. Staff did not appear busy or rushed. Additional staff were on shift to support with 121’s. We observed staff rotating tasks so to keep alert. Staff took time to speak with people and interact with them kindly.

There were systems and processes in place to ensure sufficient staffing levels, safe recruitment of staff and appropriate level of training for all staff. The provider regularly monitored staff training records to ensure it is up to date. People's changing needs were considered when deciding on the appropriate ratio of staff. There were processes in place to ensure staff receive the support they need to deliver safe care. This includes supervision, appraisal and support.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People, when asked about care, responded positively including medicines administration received from staff at the service. We received positive feedback regarding medicines management from people and their relatives. Their comments included, "The staff give[my relative] medications. [My relative] gets them on time and when they need them"; " " If [my relative] does not take it [medication], then they patient with them. They [staff] are so kind".

Staff were observed to be caring when a medicine round was observed. Staff members did not rush people to take medicines. Staff told us they received training to manage medicines and had their competency checked to ensure they were safe. Training records were provided to evidence this. Staff told us they enjoyed working at the home and felt supported and were part of a team that was caring. Staff understood and followed procedures to ensure people’s medicines were reconciled when they moved between services and when changes occurred by the GP or hospital.

There were processes in place to ensure the safe and effective use of medicines and staff followed these. The provider’s role with people’s medicines was clearly defined and described in relevant policies, procedures, and training. The provider did regular medicine audits to ensure medicines were managed safely. However, some documents to support staff lacked detail and were not always person-centred. Some information was missing or outdated on administration records including accurate allergy information and how the medicines should be administered. When required (PRN) protocols sometimes lacked sufficient information to support staff to understand how and when to administer a medicine to a person. The provider had taken action to address these points following the inspection.