Heronsmere Home Care Ltd received an overall Good rating at its November 2023 inspection, with Safe rated Good and Well-led rated Requires Improvement. The main concerns centred on inconsistent governance, incomplete audit systems, and a lack of formal supervision and appraisal records, though the registered manager took prompt action to address issues raised during the inspection.
Concerns (4)
moderateGovernance: “Audits were not completed regularly which meant there was limited information in place to see how the service was being managed.”
moderateSupervision / appraisal: “Supervisions and appraisals were not consistently happening; this was because the registered manager had periods of maternity leave over the last two years.”
moderate
Record keeping
: “The registered manager did not always have effective quality assurance systems in place to monitor the service. The registered manager was aware of the need to improve record keeping.”
minorCare planning: “We noted 1 person's risk assessment needed updating to ensure there was clear information to guide staff.”
Strengths
· Medicines were managed safely and people received their medicines as prescribed.
· Effective infection prevention and control procedures were in place.
· Staff understood how to safeguard people from the risk of harm and received safeguarding training.
· Sufficient staff were deployed to provide care and support.
· Staff recruitment was carried out safely.
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood