Archived: Herries Lodge

Updated 7 September 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This comprehensive inspection took place on 30 July 2018 and was unannounced. The inspection team consisted of two adult social care inspectors, an assistant adult social care inspector 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 expert-by-experience had experience in caring for older people and people living with dementia.

Before this inspection we reviewed information available to us about the service, which included correspondence we had received and any notifications submitted to us by the service. A notification contains information about important events which the registered provider is legally required to send us. For example, where a person who uses the service suffers a serious injury. We took this information into account when we inspected the service.

Before this inspection we contacted social care commissioners who help arrange and monitor the care of people living at Herries Lodge. We also contacted Healthwatch Sheffield. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the comments and feedback received from these organisations to inform our inspection.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. The PIR contains information we usually require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.

During this inspection we spoke with 10 people living at Herries Lodge and three of their relatives. We spoke with a health professional visiting the service on the day of our inspection and the hairdresser who visited every week. We spoke with 10 members of staff. This included four care assistants, two team leaders, a domestic assistant, the cook, the deputy manager and the registered manager. We also spoke with the district manager who was visiting Herries Lodge on the day of our inspection.

We looked at three people's care records, four medication administration records and three staff files. We looked at other records relating to the management of the home and the quality of the service provided. This included quality assurance audits and training and supervision records.

We asked the registered manager to send us a range of documents following the inspection. The documents were all provided within the timescales requested.

We spent time observing the daily life in the service, including the care and support being delivered by staff. We walked around the home and looked in the communal areas, including the bathrooms, the kitchen, the lounges and the dining areas. With their permission we also looked in people's bedrooms.

Updated 7 September 2018

This inspection took place on 30 July 2018 and was unannounced. This meant no-one at the service knew we were planning to visit.

Herries Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Herries Lodge provides accommodation and personal care for up to 47 older people with a range of support needs, including people living with dementia. The home is an adapted building over three floors, with access to a garden. At the time of our inspection there were 45 people using the service.

Our last inspection of Herries Lodge took place on 7 September 2016. We rated the service good overall, but requires improvement in the key question of well-led. We found there was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; good governance. This was because the maintenance certificates for the fire alarm system, emergency lighting system and the emergency call bell system had expired in March or April 2016 and this had not been identified by the service’s health and safety audits.

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key question of well-led to at least good. At this inspection we found sufficient improvements had been made to meet the requirements of regulation 17. The necessary maintenance certificates for the premises and for equipment used by the service were up to date. The provider had an effective system in place to monitor this.

At this inspection we found the evidence continued to support the overall rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

There was a registered manager employed at Herries Lodge. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe. There were enough staff available to meet people's needs in a timely way and to keep people safe. However, we have made a recommendation about the system the service uses to calculate staffing levels within the home.

Staff understood what it meant to protect people from abuse. They told us they were confident the management team would take any concerns they raised seriously. The registered manager made appropriate referrals to the local safeguarding authority when this was necessary.

Medicines were stored safely and securely, and procedures were in place to ensure people received their medicines as prescribed.

Procedures for recruiting new staff had recently been improved to help make sure the staff employed at the service were of suitable character.

Staff received a range of training which the provider considered to be mandatory. Staff told us they were happy with the training they received and felt it supported them to do their roles. People living at Herries Lodge told us the staff were well trained.

People told us the staff were kind and caring. During this inspection we observed the staff treat people with kindness, dignity and respect.

Staff were supervised regularly by the management team however we saw that supervisions did not always take place as frequently as the provider’s supervision policy required. We have made a recommendation about the service’s supervision procedures.

People were asked for consent before care was provided to them. Where people lacked capacity to make certain decisions for themselves, their care records contained evidence that decisions had been made in their best interests. People were supported to have maximum choice and control over their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

The service worked closely with community health professionals to support people with their health needs. People’s care records evidenced they received medical attention when they needed it, to promote their health.

People’s needs were assessed when they moved into Herries Lodge and detailed care plans were in place to guide staff in how to care for each person. Care plans were reviewed regularly to make sure people received the correct levels of care and support. Care plans contained details of people’s life histories and their likes and dislikes. This assisted staff to provide person centred care to people living at Herries Lodge.

There were activities taking place within Herries Lodge however some people told us they would like more to do. People told us they could not access the garden as much as they would like to.

People, their relatives and the staff all spoke highly of the registered manager. Staff told us they could always approach the registered manager if they needed support or if they had any concerns. The registered manager, the deputy managers and the provider completed regular audits of the service to make sure action was taken and lessons learned when things went wrong. This meant systems were in place to support the continuous improvement of the service.

Further information is in the detailed findings below.