CQC report explained · a nursing home
What the CQC found at Heathbrook House 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
- Medicines, staffing and risk management had improved, but medicine records still had gaps, some safeguarding concerns had not been reported as required, and some infection control and safety procedures were not always followed.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- People's needs and preferences were generally understood and met. Care records, communication support, activities, visiting arrangements and complaints handling were viewed positively, although some records needed more information.
- Well-led?
- Requires improvement
- Management oversight had improved, but quality checks and records were still not consistently effective. There had also been several management changes, which left some staff feeling unsettled and unsupported.
What inspectors found, February 2023
Overall rating Requires Improvement; inspectors found improved staffing and responsive care, but governance systems remained in breach.
This was an unannounced, focused inspection on 23 January 2023. Inspectors looked at Safe, Responsive and Well-led. They spoke with people living at the home, relatives and staff, and checked care, medicines, management and recruitment records.
There had been improvements since the previous inspection. People received their medicines when needed, staffing levels had improved, and the home was clean. People felt safe, and inspectors found that care was responsive. Activities, visiting and complaints arrangements were also viewed positively.
The overall rating was Requires Improvement. Safe and Well-led were also Requires Improvement, while Responsive was Good. The provider was still in breach of Regulation 17 because its checks and records did not consistently show that care was safe and well managed. Effective and Caring were not inspected during this visit, so their previous ratings were carried forward into the overall rating.
Improved staffing
People, relatives and staff generally said staffing levels had improved. Inspectors found that recruitment procedures were safe and there were enough staff to meet people's needs.
“Staff told us staffing levels had improved and there were enough of them to meet people's needs.” from the report
Responsive daily care
People said staff usually responded to their needs and knew their routines and preferences. Meals and care were provided in a timely way during the visit.
“During our visit care and support was provided in a timely way.” from the report
Activities and relationships
People were supported to keep in touch with family and friends. They were happy with activities, which included visits from school children and faith groups.
“People were happy with the social activities available to them which included weekly visits from school children and representatives from faith groups to support religious needs.” from the report
Improved medicines safety
Inspectors found enough improvement for the previous breach relating to medicines to end. People said they received their medicines when needed, although record keeping still needed work.
“People told us they received their medicines when they needed them.” from the report
Weak governance and records
seriousThe provider's systems did not reliably check and improve quality and safety. Some care and medicine records were incomplete or out of date, and this remained a legal breach.
“Systems were not established or operated effectively to assess, monitor and improve the quality and safety of the service.” from the report
Inaccurate care information
seriousTwo people's care records did not contain enough current information to guide safe care. Inspectors found similar concerns at the two previous inspections.
“Care records for 2 people lacked up to date accurate information which placed them at risk of receiving unsafe care.” from the report
Safeguarding reporting
seriousOne safeguarding concern had not been reported to CQC as required, and another incident record was unclear. The provider submitted notifications after the inspection.
“However, the provider's processes were not always followed because 1 safeguarding concern had not been reported to us as required.” from the report
Some medicines and infection procedures
needs fixingSome medicines awaiting disposal were not stored in tamper-proof containers, and some staff wore jewellery that created an infection control risk. Action was taken after the visit.
“Medicines were not always disposed of in line with current best practice guidance.” from the report
Management changes
needs fixingThere had been several management changes. Some staff said this made them feel unsettled and unsupported, and the new manager had been in post for only one week at the inspection.
“Staff explained the management changes had made them feel unsettled and unsupported.” from the report
- 01How will you make sure every person's care record is accurate, current and detailed enough to guide safe care?
- 02What checks now make sure all safeguarding concerns are reported to CQC when required?
- 03How are you checking that medicines awaiting disposal are stored securely and that medicine records have no gaps?
- 04What is being done to give staff stable leadership and improve morale after the recent management changes?
- 05When will the planned electronic care and medicines systems be introduced, and how will you show that improvements are lasting?
This was a focused inspection of Safe, Responsive and Well-led only; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 24 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, May 2022
Requires Improvement; inspectors found continued risks with medicines, staffing and risk management, with breaches of regulations.
This was an unannounced follow-up inspection on 7 April 2022. Inspectors spoke with people, relatives and staff, and checked care records, medicines records, audits and infection control arrangements.
The home was rated Requires Improvement overall. Safe improved from Inadequate at the previous inspection, but remained Requires Improvement. Well-led remained Requires Improvement. The report did not give ratings for Effective, Caring or Responsive.
Inspectors found that medicines were not always given or recorded safely. Staff did not always follow instructions to reduce risks such as falls, skin damage and unsafe hoist use. Staffing had increased, but people could still face long waits for help.
There were improvements in infection control, some wound and equipment safety, and the management team had new improvement plans. However, the home remained in breach of regulations about safe care, governance and staffing.
Improved infection control
Inspectors found that infection prevention and control had improved, and visits were taking place safely in line with government guidance.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
People generally felt safe
People spoken with said they felt safe living at the home. Staff understood their safeguarding responsibilities and the manager shared concerns with the relevant authorities.
“People felt safe living at Heathbrook House.” from the report
Some safety improvements
There had been improvements in wound management, equipment safety and some areas of fire safety. The home also took some immediate action after inspectors raised concerns.
“Some areas of risk management had improved since February 2022, including the management of wounds, equipment safety and some aspects of fire safety.” from the report
Improving leadership
Staff spoke positively about the new manager and said the culture was improving. A new clinical services manager had also been appointed to strengthen clinical oversight.
“A new clinical services manager had been recruited two weeks prior to our visit to strengthen the management team and improve clinical oversight of the care provided.” from the report
Medicines were not consistently safe
seriousSome medicines were not given as prescribed, and records did not always show what had been given or why. Inspectors said this placed people at risk of harm.
“We found no evidence that people had been harmed however systems and processes were not sufficient to demonstrate people's medicines were managed and administered safely.” from the report
Risk instructions were not followed
seriousStaff did not consistently follow instructions to reposition people at risk of skin damage. Inspectors also found an unsuitable sling was used for one person and that some risk assessments were not up to date.
“Staff had not consistently followed those instructions which placed the people at risk.” from the report
Staffing was not always sufficient
seriousOne person waited more than 20 minutes for a call bell to be answered, and some people waited for meals. Feedback about staffing was mixed despite staffing levels having increased.
“Sufficient numbers of staff were not always available to meet people's needs.” from the report
Checks and records were not reliable
seriousAudits did not always cover important medicines, and care records and risk assessments did not always contain accurate information. This meant problems could be missed.
“Systems were not established or operated effectively to assess, monitor and improve the quality and safety of the service.” from the report
Mixed views about leadership
needs fixingMost people knew the manager and staff described improvements, but relatives gave mixed views and some had lost confidence in the home. The manager planned meetings with relatives to rebuild relationships.
“However, relative's expressed contrasting views when we sought their views about the leadership of the service.” from the report
- 01How are you now checking that every medicine is given as prescribed and that all administration records are complete?
- 02How do you make sure staff follow each person's repositioning, falls and moving-and-handling instructions?
- 03What staffing levels and skill mix are planned for each shift, and how will you prevent delays answering call bells or serving meals?
- 04How much agency staff are currently being used, and how are agency workers shown each person's up-to-date risks and care instructions?
- 05What checks now confirm that audits identify problems and that improvement actions have been completed?
This was an unannounced follow-up inspection focused on Safe and Well-led, including infection control; Effective, Caring and Responsive were not assessed in this report. This explanation was written from the published report of 14 May 2022 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 Heathbrook House Care Home
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- February 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2022Requires improvementSafe: InadequateWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- March 2020Goodstayed GoodSafe: GoodResponsive: Requires improvementWell-led: Good
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
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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