CQC report explained · a nursing home
What the CQC found at Heatherdale Healthcare Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed, staff were available to support people, medicines were administered safely and infection control arrangements were in place.
- Effective?
- Good
- Staff had relevant training and supervision. People's nutrition, health needs and capacity to make decisions were assessed and supported.
- Caring?
- Good
- This key question was not covered by this focused inspection. People and relatives nevertheless gave positive feedback about staff's care and kindness.
- Responsive?
- Good
- Care plans reflected people's needs and preferences. Complaints were recorded and investigated, and people were offered activities and support to stay in contact with relatives.
- Well-led?
- Good
- Inspectors found a clear management structure and improved systems for monitoring care, risks, complaints and staff training.
What inspectors found, July 2021
Rated Good; inspectors found safe, kind and better-organised care, with some monitoring and staff feedback still needing attention.
This was an unannounced, focused inspection on 26 May 2021. Inspectors spoke with people, relatives, staff and health professionals. They observed care, a staff meeting and part of lunch, and checked care, medicine, recruitment, training and management records.
The home was rated Good for Safe, Effective, Responsive and Well-led. People and relatives gave mostly positive feedback. Inspectors found enough staff, safer medicines arrangements, trained staff, personalised care plans, activities and improved checks on quality.
The home had previously been rated Requires Improvement in 2018, with breaches linked to risk management, complaints and governance. Inspectors said improvements had been made and the home was no longer in breach. This inspection did not cover Caring, and some ratings were carried forward from the previous comprehensive inspection.
Staffing and safety
Staff were deployed according to people's needs. Inspectors saw people receiving help when needed and call bells being answered promptly.
“At this inspection the provider continued to use a dependency tool to help ensure there were sufficient levels of staff during the day and night.” from the report
Medicines
The home had clear instructions for medicines given when needed. Trained staff managed ordering, storage and stock control.
“People received their medicines as prescribed with dedicated trained staff to manage stock control, ordering and safe storage of medicines.” from the report
Personalised care
Care plans included people's health, social and emotional needs. Staff knew people's preferences and supported them in a person-centred way.
“People had a personalised plan for their care that reflected their needs and preferences.” from the report
Training and skills
Staff completed training linked to people's needs, including nursing training and specific training for conditions such as diabetes, Parkinson's disease and epilepsy.
“At this inspection care and nursing staff had undertaken a programme of training which reflected people's needs.” from the report
Improved management
Inspectors found better quality monitoring, including checks on clinical care, risks, infection control, health and safety, care plans and complaints.
“At this inspection improvements had been made to quality monitoring systems.” from the report
Medicines audit detail
minorThe medicines audit found no concerns, but it did not record whose medicines had been checked. The provider agreed to include this information in future.
“Although the medicines audit found no concerns, it did not identify whose medicines were checked to ensure there was a random sampling of everyone's medicines records.” from the report
Mixed staff feedback
needs fixingThe most recent staff survey mentioned in the report showed that fewer than half of staff recommended working for the home. The home was sending out a new survey to get more up-to-date views.
“In this survey only six out of 13 staff recommended working for the service.” from the report
Planned decoration
minorRelatives considered the furnishings and decoration adequate, but further decoration and garden work were still planned.
“There were plans for additional decoration and for the garden.” from the report
- 01How do you now check that medicines audits sample everyone's records and identify whose records were checked?
- 02What did the latest staff survey find, and what action have you taken in response to the earlier mixed staff feedback?
- 03What improvements to the garden and decoration have been completed, and what remains planned?
- 04How do you check that care remains kind, dignified and respectful, given that Caring was not covered in this inspection?
- 05How are complaints, accidents, clinical risks and care plan checks reviewed, and how do you share lessons with staff?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not covered, and ratings for key questions not inspected were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 10 July 2021 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, January 2021
Heatherdale Healthcare Limited was inspected but not rated; its previous Requires Improvement rating remains, with staffing and infection-control issues found and addressed during the visit.
This was a targeted inspection on 9 and 16 December 2020. Inspectors looked specifically at infection control and staffing, rather than the whole service.
People told inspectors they were happy and felt well looked after. There were enough staff for people's care needs, staff recruitment checks had been completed, and staff were using protective equipment correctly.
Inspectors found that night staffing had been reduced without checking whether there were enough staff to evacuate people safely in an emergency. The provider increased night staffing immediately and arranged a fire safety check.
The overall service was inspected but not rated. The previous overall rating of Requires Improvement remains because this inspection did not assess the full service or the whole Safe question.
People felt well cared for
The people inspectors spoke with said they were happy living at the home and felt well looked after.
“They are very pleasant. I feel well looked after and am happy to be here.” from the report
Infection-control measures
Inspectors found suitable measures to reduce infection risks. Staff had PPE and were using it correctly and in line with guidance.
“Staff were using PPE correctly and in line with current guidance.” from the report
Recruitment checks
The home completed checks such as references, DBS checks and nurse registration checks before staff started work.
“Checks had been completed to ensure nurse staff were appropriately registered with Nursing and Midwifery Council.” from the report
Night staffing and emergency evacuation
seriousNight staff numbers had been reduced without checking whether people could be evacuated safely in an emergency. The provider increased night staffing during the inspection and arranged a fire safety check.
“They had not checked there remained sufficient staff to evacuate people safely if there was an emergency such as a fire.” from the report
Missing risk assessment
needs fixingA person who had tested positive for COVID-19 was recorded as having a history of wandering, but this was not included in their care plan and there was no risk assessment. The risk assessment was added during the inspection.
“There was no information about this in the person's care plan and a risk assessment had not been completed.” from the report
Some guidance needed updating
minorSome infection-control guidance was out of date. The home addressed this during the inspection.
“During the inspection there were some areas of guidance which were not up to date.” from the report
- 01What are the current night staffing levels, and how have you checked that they are enough to evacuate everyone safely?
- 02What was the outcome of the fire safety check arranged during the inspection?
- 03How do you make sure people's care plans and risk assessments reflect wandering or other infection-control risks?
- 04How do you check that infection-control policies and guidance remain up to date?
- 05When will the next comprehensive inspection take place, and what improvements are being made to address the previous Requires Improvement rating?
This was a targeted inspection of specific concerns about infection control and staffing; it did not assess the whole Safe question or change the previous ratings. This explanation was written from the published report of 23 January 2021 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 Heatherdale Healthcare Limited
4 rated inspections over 5 years: the service has held its Good rating throughout.
- July 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Heatherdale Healthcare Limited →
- January 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Heatherdale Healthcare Limited →
- September 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- February 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 2011.
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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