Hereward College was rated Requires Improvement overall, with a breach of Regulation 17 (Good Governance) due to unsafe medicine storage, inadequate covert medicine procedures, and audits that failed to identify these issues. Effective, caring and responsive domains remained Good, with person-centred care, strong staff training and an open culture, though caring deteriorated from Outstanding to Good.
Concerns (8)
critical
Medication management
: “We identified a fridge used to store medicines was not operating consistently within the recommended temperature range to help maintain the effectiveness of the medicine.”
criticalMedication management: “A best interest decision was not recorded about this decision... A covert medicine policy was not in place and a pharmacist had not been consulted to ensure the way the medicines were administered was safe.”
criticalGovernance: “Systems in place to assess, monitor and improve the quality of the service were not robust and did not drive the required improvements.”
moderateMedication management: “instructions on how one medicine should be taken conflicted with the guidance on the protocol. This meant the medicine may not be effective if given.”
moderateGovernance: “We found the audits of the service did not cover all aspects of care delivered and meant risks may not be identified and acted upon.”
moderateIncident learning: “Analysis of accidents and incidents was not completed to identify patterns or trends throughout the service however actions were taken for individuals to prevent a re-occurrence.”
moderateConsent / capacity: “One person was given some of their medicines covertly. A best interest decision was not recorded about this decision”
minorRecord keeping: “audits were not accurately dated and only stated 'September 2021' this meant it was not possible to be precise about when the checks had been completed”
Strengths
· Robust pre-employment and recruitment checks including criminal history checks
· Staff trained in safeguarding and whistleblowing; people felt safe with staff
· Person-centred care promoting dignity, independence and human rights
· Effective infection prevention and control measures with adequate PPE
· Staff received regular supervision, appraisals and reflective practice
Quality-Statement breakdown (24)
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; supporting people to access healthcareGood
effective: Adapting service, design, decoration to meet people's needsGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships and follow interestsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about roles, understanding quality performance, risks and regulatory requirements; Continuous learningRequires 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
well-led: Engaging and involving people, public and staff; working in partnership with othersGood