What the CQC found at Heathland Court Care Home

The home had recruitment records showing applications, references, identity checks and DBS checks for the files reviewed.

“We reviewed staff recruitment files and found these contained a completed application form, satisfactory references, photographic identification and a Disclosure and Barring Services (DBS) check.” from the report

Inspectors found that people were protected from abuse and that staff understood how to raise safeguarding concerns.

“People were protected against the risk of abuse.” from the report

Although pain relief was not always given promptly, the medicines records checked were complete and stock balances were accurate.

“Medicine Administration Records (MARs) were completed accurately with no gaps or omissions. Stocks and balances were accurate.” from the report

Inspectors were assured about the home's infection prevention arrangements, including PPE, admissions and responding to infection risks.

“We were assured that the provider was using PPE effectively and safely.” from the report

Repositioning records were inconsistent, and some people waited longer than healthcare professionals had advised. This put people at risk of pressure wounds.

“Records showed repositioning checks were inconsistent, with some people waiting longer than advised to be repositioned. This meant people were at risk of developing pressure wounds.” from the report

Some staff worked a 12-hour night shift followed by a further six-hour shift. Inspectors said staffing levels were not always enough to keep people safe and meet their needs.

“During the inspection we reviewed the staff rota and identified there were occasions whereby night staff had worked a 12 hour shift and were then rostered to work the morning shift for an additional six hours.” from the report

Accidents and incidents were not always recorded or investigated. Inspectors found no evidence that lessons had been learned from one skin tear.

“Accidents and incidents weren't always recorded to monitor trends and patterns.” from the report

The home's audits failed to identify problems with repositioning, staffing and incident records. This led to a breach of the good governance regulation.

“Audits undertaken failed to identify staff were not repositioning people as required in their care plan, staffing levels were not adequate to meet people's needs and records were not easily accessible or indeed in place.” from the report

Staff described a culture where some people were afraid to report poor practice. Inspectors also heard concerns about derogatory and racially offensive language between staff.

“Staff also confirmed some staff referred to their colleagues using derogatory and racially offensive language.” from the report

Inspectors observed two people asking for pain relief, but neither received it swiftly because staff were focused on task-based activities.

“People did not always receive pain relieving medicines in a timely manner.” from the report