What the CQC found at Heather Holmes Care Home

Inspectors saw positive interactions and found that people appeared comfortable with staff. People and relatives said staff were caring and respectful.

“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report

Care plans reflected people's individual needs, preferences and what mattered to them. Staff adapted support when people's preferences changed.

“People's care plans were individual to them and kept under regular review.” from the report

People were encouraged to make daily choices and develop independence. The home supported people to take part in social, therapeutic and recreational activities.

“The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion.” from the report

Staff received induction, ongoing training, supervision and appraisals. Staff said they felt supported in their roles.

“Staff received an initial induction, followed by ongoing training and support to help them succeed in their job roles.” from the report

Risk assessments were not consistently reviewed after incidents. One person had many falls over the previous year, but this was not identified promptly and post-fall monitoring was not in place.

“Risk assessments had not always been evaluated in line with organisational policy or updated following incidents, such as falls or altercations between people who lived at the service.” from the report

Safety checks were not always recorded, and concerns such as unsafe water temperatures were not always followed up.

“Staff had not consistently recorded checks to monitor the safety of the environment and had not always followed up concerns identified by health and safety checks.” from the report

Some infection control practices were not followed consistently. Inspectors saw an uncovered commode pail being carried through the home and an unclean shower chair stored in a corridor.

“One member of staff was seen carrying a commode pail uncovered from a person's bedroom to a toilet.” from the report

The provider's quality systems did not reliably identify problems or ensure accurate and complete records. This contributed to the breaches of Regulations 12 and 17.

“The provider's quality assurance processes had not ensured staff maintained accurate and complete records in relation to whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met.” from the report

The provider was unclear about the status of applications for Deprivation of Liberty Safeguards authorisations. Inspectors were satisfied that people were generally supported in their best interests and encouraged to make decisions.

“However, the provider did not have clarity on the status of applications for DoLS authorisations for the people living at the service.” from the report

Staff had not recorded all informal and formal complaints. The home also lacked procedures to record people's end of life wishes, although nobody was receiving end of life care during the inspection.

“The provider did not have procedures in place to establish and record people's wishes regarding their end of life care, so these could be acted upon.” from the report