What the CQC found at Heathfield House

Inspectors found enough suitably skilled staff, and staffing levels were adjusted when people's needs required it.

“People told us and we saw there were enough suitably skilled staff to support people in line with their agreed needs.” from the report

Medicines were mostly ordered, stored, given, recorded and disposed of safely. One storage issue involving medicines pots still needed improvement.

“We saw that medicines were mostly managed safely. This included the; ordering, storage, administration, recording and disposal of medicines.” from the report

People and relatives spoke positively about the home. Staff knew people's needs and risks, even though records were not always reliable.

“Despite this, care staff had a good understanding of people's needs and risks.” from the report

People were supported to make choices about food, décor and activities, and to enjoy things both at the home and in the local community.

“People told us and care records showed they were supported to do the things they enjoyed both at the service and in the local community.” from the report

Care plans did not always reflect people's current needs. Falls were not always reviewed properly, so action to reduce further harm was not assured.

“When people fell, their risk of falling again was not always reviewed which meant action was not always taken to reduce the risk of harm from further falls.” from the report

Five falls involving three people caused injuries needing first aid or medical care, but none were reported to the local authority as potential omissions of care or neglect.

“None of these had been reported to the local authority as potential omissions of care/neglect as required.” from the report

Mental capacity assessments were missing, and people subject to restrictions did not have the required Deprivation of Liberty Safeguards applications or authorisations. One person's medicine was routinely given covertly against professional advice.

“All of these people had restrictions upon them that would be classed as a deprivation of liberty.” from the report

Quality audits had not identified the problems found during the inspection. There was no effective system for investigating incidents and preventing them happening again.

“The auditing systems in place to assess and monitor safety and quality were not effective and had not identified the concerns detailed in this inspection report.” from the report

References and DBS checks were not always completed promptly. Where checks were delayed, risk assessments were not completed.

“Where there were delays in obtaining references and/or DBS checks, risks assessments were not completed to ensure the risks associated with staff working without these checks had been assessed and managed.” from the report

Frayed carpets and an uneven floor in a dark corridor increased the risk of falls. These hazards were not recorded in an environmental risk assessment or improvement plan.

“Some carpets at the home were frayed and there was an uneven floor in a dark area of corridor increasing the risk of falls.” from the report