CQC report explained · a residential care home
What the CQC found at Herne Place Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risk assessments were not up to date or did not match care plans. Inspectors found enough staff during the visit, safe recruitment checks, safe medicines practice, safeguarding arrangements and effective infection control.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- There was no registered manager in post at the inspection. Audits had identified gaps in care records, although managers were open about the problems and improvement work was under way.
What inspectors found, February 2023
Herne Place Care Home was rated Requires Improvement; inspectors found enough staff and caring practice, but risk records and management oversight were not always reliable.
This was an unannounced focused inspection on 12 January 2023. Two inspectors spoke with four people and seven staff, observed care, and reviewed care plans, medicines records and management records.
The home was rated Requires Improvement overall. Safe and well-led were both rated Requires Improvement. Inspectors found gaps and inconsistencies in some risk assessments and care records, including missing evacuation plans. These records were already being checked and updated.
Staffing had been difficult in recent months, with agency staff covering gaps and night vacancies still being recruited to. Inspectors found enough staff during the visit, safe recruitment checks, safe medicines practice, safeguarding knowledge and effective infection control.
The inspection only assessed Safe and well-led. The other three ratings were carried over from the previous inspection, which had rated the service Good in November 2021.
Safe recruitment
New staff had been recruited with checks on employment history, references and DBS information.
“Staff had been recruited safely. Records were kept in the service and showed correct checks had been made on employment history, references and of the Disclosure and Barring Service (DBS).” from the report
Medicines support
Inspectors saw safe and respectful medicines support. Staff had current competency assessments for giving medicines.
“We observed good, safe and caring interactions by staff with people when giving their medicines.” from the report
Safeguarding
Staff understood how to recognise and report abuse or harm. Safeguarding alerts had been raised and investigated appropriately.
“Staff received safeguarding training and were able to demonstrate the different types of abuse a person may be at risk of and how they would report this if they were concerned.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements to prevent and manage infections, including effective use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Open improvement work
The management team acknowledged the problems found and had begun reviewing records and improving staffing. Staff described a positive change in the culture.
“The manager and deputy manager were open and honest throughout inspection regarding any identified shortfalls and developed actions to take to improve these.” from the report
Incomplete risk records
seriousSome people did not have current or relevant risk assessments. One assessment described different hoisting equipment from the person’s care plan, and some people did not have evacuation plans.
“Some people did not have up to date and relevant risk assessments. We found inconsistencies between people's care plan and risk assessments.” from the report
Management arrangements
needs fixingThere was no registered manager at the time of the inspection. A new manager had applied to register, but the application was still being assessed.
“At the time of our inspection there was not a registered manager in post.” from the report
Staffing vacancies
needs fixingThe home had experienced staffing problems. Night vacancies were being covered by agency staff while recruitment continued.
“These positions were being covered with agency staff until new applicants were in post.” from the report
Paused meetings
minorMeetings with residents, relatives and staff had stopped after the previous registered manager left. The home planned to resume them after the new manager’s induction.
“Meetings with residents, relatives and staff had been completed until the previous registered manager left their post.” from the report
- 01Have all residents’ risk assessments and care plans now been reviewed so they match the equipment and support each person needs?
- 02Does every resident now have a current Personal Evacuation and Escape Plan?
- 03How many night staff are permanent, and how are agency staff made familiar with residents’ needs and risk plans?
- 04Has the new manager’s registration application been completed, and who is responsible for oversight until then?
- 05Have meetings with residents, relatives and staff restarted, and what changes have resulted from the feedback?
This was a focused inspection of Safe and well-led only; the Effective, Caring and Responsive ratings were carried over from the previous inspection in 2021. This explanation was written from the published report of 25 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2021
Rated Good overall, but inspectors found the home was not always well-led because there was no registered manager in post.
This was the home’s first inspection. It was unannounced and took place over 4 and 6 October 2021. Inspectors spoke with people, relatives, staff and visiting professionals. They also observed care and checked care, medicines, recruitment and management records.
Inspectors rated the home Good for safe, effective, caring and responsive care. People and relatives said they felt safe, treated with respect and supported as individuals. Staff were trained, medicines were managed safely, and people had access to activities, food, healthcare and end-of-life support.
The home was rated Requires Improvement for being well-led. There was no registered manager, although the manager knew the service well and an application to become registered manager was being considered. The provider had audits and checks in place, and inspectors found a positive culture.
People felt safe
People and relatives told inspectors they felt safe. Staff understood how to recognise abuse and raise concerns.
“People were supported to remain safe by staff who could recognise signs of abuse.” from the report
Kind and respectful care
Inspectors found that staff treated people with kindness and dignity. People were offered choices and encouraged to remain as independent as possible.
“Staff demonstrated respect for people and treated them with kindness and dignity.” from the report
Good activities and social contact
Activities were planned throughout the week and tailored to people’s interests. One-to-one sessions were available for people who did not want to join group activities.
“The schedule of things to do included one to one sessions.” from the report
Support with health and nutrition
People had access to healthcare professionals, and their nutrition and hydration needs were assessed. Staff also supported people receiving end-of-life care.
“Staff worked in partnership with healthcare professions and social workers to ensure people remained as healthy and safe as possible.” from the report
No registered manager
seriousThe home did not have a registered manager when inspectors visited. This was against a condition of the home’s registration, although an application was being considered.
“The location has a condition of registration with CQC that it must have a registered manager, but there was not one in post at time of inspection.” from the report
- 01Has the manager’s application to become registered manager been completed and approved?
- 02Who is legally responsible for the home while there is no registered manager?
- 03How are senior leaders checking that the home’s audits and daily management systems remain effective?
- 04How will you keep relatives informed about progress towards having a registered manager?
- 05Can you explain how activities and one-to-one social contact will be tailored to my relative’s interests?
This was the home’s first unannounced inspection and covered all five CQC questions, including infection prevention and control measures. This explanation was written from the published report of 6 November 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Herne Place Care Home
2 rated inspections over a year: the service has slipped, from Good to Requires improvement.
- February 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2021GoodSafe: GoodWell-led: Requires improvement
- June 2020
Registered with the Care Quality Commission on 3 June 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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