CQC report explained · a residential care home
What the CQC found at Heatherlea House Residential 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
- Inspectors found that risks were not always identified, assessed or reduced. Medicines records were inaccurate, and some as-needed medicines did not have clear instructions.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Quality checks did not always find problems or record how they would be fixed. The recruitment policy and arrangements for staff promoted to senior roles also needed improvement.
What inspectors found, March 2023
Requires Improvement; inspectors found gaps in risk management, medicines and management oversight.
This was an unannounced inspection on 06 February 2023. Two inspectors spoke with 9 people, 5 staff and the provider. They observed care and reviewed care, medicines, recruitment and management records.
Inspectors found that risks were not always properly assessed or reduced. Some stair safety actions had not been completed, bedrail covers were not always used as assessed, and some bedroom wardrobes were not secured. Medicines records were inaccurate and instructions for some medicines were missing.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected and kept their previous ratings, so the overall rating changed from Good at the last comprehensive inspection in 2018.
People felt safe
People told inspectors they felt safe living in the home. Staff knew how to recognise and report possible abuse.
“I'm definitely safe here; they really look after me.” from the report
Person-centred care
Inspectors saw staff discussing how people wanted to be supported. People said staff knew their preferences.
“They know how I like things done and they always do it right.” from the report
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including the safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff support
Staff said they felt supported and confident about raising issues or ideas for improvement.
“Staff told us they felt supported in their work and were confident to raise issues or ideas for improvement.” from the report
Unmanaged safety risks
seriousSome known risks had not been dealt with. Stair safety actions from 2019 were still incomplete, some bedrail covers were missing or inadequate, and 9 wardrobes were not secured to walls.
“Following a serious incident there was no evidence to show the registered manager and provider had learned lessons and taken action to reduce the risk of people falling and being injured on stairs.” from the report
Medicines records and instructions
seriousRecords for medicines needing extra controls were inaccurate. Some as-needed medicines did not have instructions explaining when and how staff should give them.
“This meant staff did not have clear guidance as to when and how to administer these medicines.” from the report
Weak quality checks
needs fixingAudits did not identify several problems found by inspectors. Action plans were also not consistently recorded, including for fluctuating hot water temperatures.
“Systems for monitoring the quality of the service were not always effective.” from the report
Recruitment records
needs fixingThree staff files did not contain required references, and the manager could not locate the risk assessments said to have been completed before references were returned.
“However, risk assessments could not be located by the registered manager.” from the report
Senior staff training
needs fixingThere was no system to make sure care workers promoted to senior roles received additional training for their new responsibilities.
“There was no system in place to ensure care workers who were promoted to senior caring roles had additional training.” from the report
- 01What has been done to secure the stairwells and bedroom furniture, and how are these changes now checked?
- 02How are risk assessments and care plans being reviewed, especially for falls, choking, nutrition and bedrails?
- 03How do you now check medicine records and make sure as-needed medicines have clear instructions?
- 04What action plan did you send to CQC, and what progress has been made on each action?
- 05How do you check references and risk assessments for new staff, and what extra training do senior care workers receive?
This was a focused, unannounced inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings carried over from the last comprehensive inspection. This explanation was written from the published report of 31 March 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, August 2021
Inspected but not rated; inspectors found people were supported safely, but some falls risk records were incomplete.
This was an unannounced targeted inspection on 15 July 2021. Inspectors looked mainly at how the home managed risks linked to people's mobility and falls. They also checked infection prevention and control measures.
Inspectors found that people were supported to move safely and remain as independent as possible. Staff had relevant training and suitable equipment was available. People said they were happy and felt safe.
There were some weaknesses in the records. Risk plans did not always include important details about the support people received or how medicines could affect mobility. Records also did not always clearly show whether falls trends had been analysed.
The service was inspected but not rated. The previous comprehensive inspection rating was Good, published in August 2018. This inspection did not examine the circumstances of a death that had been notified to CQC.
Safe mobility support
Staff supported people to move safely while helping them keep as much independence as possible.
“People were supported to move around in a safe way, whilst maintaining as much independence as possible.” from the report
Learning after falls
Staff described what they would do after a fall, including increased observation where needed. The home also took action to reduce the chance of falls happening again.
“Staff clearly described the actions they would take if anyone had a fall.” from the report
Infection control measures
Inspectors were assured about infection prevention, including PPE, testing, hygiene, admissions and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Incomplete risk plans
needs fixingSome risk plans did not accurately describe the support people were receiving. They also did not always record how medicines might affect mobility, particularly at night.
“However, risk management plans did not always reflect essential details of the support people received.” from the report
Falls trends not clearly recorded
needs fixingThe home learned lessons from individual falls, but records did not always show clearly whether wider patterns had been examined.
“Although lessons were learned from individual incidents, records did not always clearly show how any potential trends across the service had been analysed.” from the report
- 01How do you make sure each person's falls risk plan matches the support they actually receive?
- 02How do you record and review the effect of medicines on a person's mobility, especially at night?
- 03What falls trends have you identified across the home, and what changes have you made as a result?
- 04How often do you check that mobility equipment, such as hoists and walking frames, is suitable and being used correctly?
- 05What has changed since the previous comprehensive inspection in 2018?
This was a targeted inspection of falls and mobility risks, with additional infection control checks; the service was inspected but not rated and the other areas were not newly assessed. This explanation was written from the published report of 7 August 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 Heatherlea House Residential Care Home
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Heatherlea House Residential Care Home →
- August 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Heatherlea House Residential Care Home →
- August 2018GoodSafe: GoodWell-led: Good
- June 2017
Registered with the Care Quality Commission on 12 June 2017.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.