Herewards House

At our last inspection, the service was rated requires improvement and was in breach of 1 legal regulation in relation to management of medicine. At this assessment, we found a continued breach of legal regulation in relation to medicine management. We found new breaches of legal regulations relating to fit and proper persons employed, notifications and good governance. We discussed the issues and discrepancies we identified with the management team and they started making improvements.

The provider did not always ensure they used robust assurance systems and governance processes which operated across all levels of the service. Staff had not received all their training to ensure they had the most current knowledge and skills. The provider did not always ensure staff kept clear and complete records of people’s care and treatment plans and risk mitigation. The provider needed to make some improvements to ensure the environment was developed to meet the needs of people living with dementia. Some areas of premises safety needed improvement. We found there were improvements needed to ensure issues were identified and mitigated using provider's quality assurance system. The areas included risk monitoring records for people, aspects of environment safety and suitability. This meant people were at risk of harm and not receiving care they needed. The provider did not always ensure safe and proper management of medicines and recruitment. We found the provider did not inform us and the local authority about some of the notifiable incidents in a timely manner. The provider did not demonstrate they maintained consistent records to meet requirements of duty of candour. The provider had to ensure the service was consistently well-managed and improvements were sustained and embedded. We have asked the provider for an action plan in response to the concerns found at this assessment.

We found the management led an inclusive, caring and compassionate culture of the service with clear dedication and were well respected by people, relatives and staff. The management ensured sufficient staff were available to meet people's needs, covering shifts to ensure consistency in care was provided. Staff felt well supported and believed everyone worked to provide a good service for people. People had some activities and opportunities to pursue their interests in their local area with others. People’s relatives were involved in reviewing and planning their care. People’s views and decisions were listened to and considered. The provider and the staff team worked together to ensure the risks of a closed culture were minimised so that people received support based on transparency, respect and a positive culture in the service. Staff were supported to be involved in the development and continuous improvement of the service. The management team was visible within the service and worked together with staff leading by example. Staff were aware how they protected people from abuse and how they would report incidents, accidents and other concerns. Staff felt confident the issues would be addressed appropriately by the registered manager and the provider. Staff ensured people were protected from the risk of acquiring an infection during the provision of their care. Staff supported people to access different services and support from health and social care professionals to promote and achieve positive outcomes for people. Staff understood the principles of good care and treatment. People’s rights around privacy and dignity were considered and respected.