Herons Park Nursing Home

Updated 8 September 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This team that carried out the inspection on 7 July 2023 consisted of 1 inspector, 1 specialist advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The inspection team returned on 12 July 2023. On the second day of our inspection the inspection team consisted of 2 inspectors and 1 specialist advisor.

Service and service type

Herons Park Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Herons Park Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We received feedback from the local authority. We spoke with 12 people who used the service and 5 relatives of people to gain their feedback about the service. We spoke with 8 staff members including the registered manager, nurses, care staff, maintenance and the kitchen staff. We reviewed a range of records. These included care records for 5 people, samples of medicine records, daily records, care plans and risk assessments. We looked at 3 staff records and a variety of records relating to the management of the service, including audits and procedures. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 8 September 2023

About the service

Herons Park Nursing Home is a care home providing personal and nursing care to up to 82 people on three floors of one building. The home service provides support to younger adults, older people, people living with dementia and people with physical disabilities. At the time of our inspection there were 50 people using the service.

People’s experience of using this service and what we found

The providers' governance systems had not identified the shortfalls found at this inspection. Audit systems and processes failed to identify and manage effectively risks relating to the management of medicines and other aspects of the service that required improvement. There were areas of people's documentation that needed to be improved to ensure staff had the necessary up-to-date information to provide safe and consistent care.

The management of medicines was not always safe and people were at risk of not always receiving their medicines as prescribed. The systems for staff to ensure people received their medicine as prescribed were not always effective. Staff administering topical creams had no competency checks to ensure they applied people’s creams correctly.

We identified shortfalls in respect of the management of risk. For example, the management of incident and accidents. Wound care plans lacked details. Incident forms were completed but there was a lack of overview, analysis and follow-up to prevent a re-occurrence or to mitigate risk. Lessons were not always learned when things went wrong.

Staff received training and knew how to recognise and respond to safeguarding concerns., However, safeguarding incidents were not always reported to the safeguarding authority or to Care Quality Commission (CQC). Some issues reported to the registered manager remained unresolved on the second day of our inspection.

Checks of the environment were completed, staff were trained in infection control and followed hygiene practices to keep people safe from the spread of infection. People were supported to have maximum choice and control of their lives and staff provided them with care in the least restrictive way possible. The policies and systems in the service promoted this practice.

People, their relatives and staff were invited to share their feedback with the management team. Staff provided care in a sensitive and caring manner, putting people's choices and preferences at the centre. People and relatives felt able to raise concerns or complaints and were confident they would be listened to. We received positive feedback from people, their relatives and staff on the service and the management team.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 17 January 2020 and this is the first inspection. The last rating for the service under the previous provider was good, published on 18 September 2018.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, safeguarding service users from abuse and improper treatment, good governance and notification of other incidents at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.