CQC report explained · a nursing home
What the CQC found at Heathlands Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, December 2023
Rated Requires Improvement and placed in special measures; inspectors found serious weaknesses in care records, risk management and leadership despite some improvements.
Inspectors visited unannounced on 30 August and 1 September 2023. They spoke with staff and 13 relatives, observed care, and checked care records, staff files, medicines records and management systems.
The home had improved since its previous Inadequate rating, but inspectors found that these improvements had not lasted long enough to show they were secure. All five areas were rated Requires Improvement except Well-led, which remained Inadequate.
Inspectors found unclear and conflicting care plans, weak risk guidance and gaps in fire evacuation planning. They also saw a staff member force a spoon into a person's mouth. The home did have enough staff, medicines were managed safely, infection controls had improved, and food and activities were generally positive.
The home was placed in special measures because it had an Inadequate rating in a key area at two consecutive comprehensive inspections. The provider must improve and will be monitored and re-inspected.
Medicines
Inspectors found that medicines were given as prescribed, records were accurate for the six people checked, and staff training and medicine audits were in place.
“People's medicines were managed safely.” from the report
Food and drinks
The menu was varied, alternatives were offered, and snacks and drinks were available. Specialist diets were adapted to help people eat safely.
“There was a varied menu with alternatives offered at mealtimes.” from the report
Activities and relationships
People could take part in activities such as gardening, art, singing and cinema sessions. Relatives and visitors were welcomed, and important relationships were supported.
“People enjoyed a range of activities in the home including gardening, art sessions and singing entertainment.” from the report
Staff training
Staff had completed the required mandatory training and the Care Certificate. Supervisions and appraisals were up to date.
“We found staff had the training required to meets the needs of people using the service.” from the report
Working with professionals
The home worked with GPs, diabetic nurses, speech and language therapists and community psychiatric nurses to support people's health needs.
“People were supported to access health and other services to help meet their health and wellbeing needs.” from the report
Unclear risk guidance
seriousSome care plans did not explain clearly what staff should do to manage risks such as seizures or moving and transferring people. This could leave people at risk of harm.
“People's care plans did not always contain clear guidance for staff to protect people from risks.” from the report
Safeguarding and treatment
seriousInspectors saw a staff member force a spoon into a person's mouth when the person kept their mouth shut. The home made a safeguarding referral, but the provider remained in breach.
“When the person kept their mouth shut the staff member forced a spoon into a person's mouth.” from the report
Personal care needs
seriousOne person did not always receive continence or personal hygiene support promptly. On one occasion, the person had not had their pad changed or used the toilet for six hours.
“On one occasion this person had not had their pad changed or used the toilet for 6 hours.” from the report
Conflicting care plans
seriousCare records included contradictory information about allergies, pain and breathing problems. This could make it difficult for staff to provide the right care.
“People's care plans contained inaccurate and contradictory information.” from the report
Weak governance
seriousThe provider's checks had not identified or fixed important problems. There was also not enough evidence that people's views and concerns were recorded, investigated and used to improve care.
“The provider has failed to meet the requirements of the warning notice at this inspection.” from the report
Fire evacuation planning
seriousInspectors found no evidence that mock fire evacuations were taking place at night. The business continuity plan also lacked contact details for people responsible during an emergency.
“At this inspection there was no evidence mock fire evacuations were taking place at night.” from the report
- 01What specific changes have you made to ensure every person's care plan gives clear, accurate instructions about risks and personal care?
- 02How do you prevent unsafe or forceful support during eating, and how are safeguarding concerns investigated and followed up?
- 03How are night-time fire evacuation arrangements tested, and what would happen in an emergency?
- 04How do you check that continence, hygiene and other personal care needs are met promptly when someone refuses support?
- 05What conditions have been placed on the provider's registration, and what progress will you show at the next monitoring or inspection visit?
This was an unannounced comprehensive follow-up inspection covering all five key questions, after the previous Inadequate rating and enforcement action. This explanation was written from the published report of 13 December 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, February 2023
Heathlands Care Centre was rated Inadequate and remains in special measures; inspectors found serious risks in medicines, staffing, care planning and management.
This was an unannounced follow-up inspection on 7 and 8 November 2022. Inspectors observed care, spoke with staff, relatives and professionals, and checked care plans, medicine records, recruitment files, incident records and management systems.
The home remained Inadequate overall. Safe, Effective and Well-led were also rated Inadequate. Caring and Responsive were rated Requires Improvement. Inspectors found people were at risk from unsafe medicines, incomplete risk planning, missed checks, poor recruitment checks, gaps in staff training and ineffective safeguarding procedures.
There were some improvements. The home was generally clean and tidy, premises safety checks were being completed, healthcare referrals had improved, and some staff treated people kindly and respectfully. However, the provider remained in breach of regulations and had not acted on earlier recommendations about dementia-friendly design and accessible information.
The home remains in special measures. The regulator will monitor progress, request an action plan and work with the provider and local authority. It said it would usually re-inspect within six months and could take action to prevent the home from operating if sufficient improvement was not made.
Healthcare links
Inspectors found that staff were more effective at contacting healthcare professionals when people's health changed. Other professionals, including specialist nurses, dentists and podiatrists, were involved when needed.
“Staff worked more effectively when people needed to be referred to healthcare professionals when their health deteriorated or changed.” from the report
Some respectful care
Some staff spoke to people calmly and respectfully. Inspectors also saw medicines being given at people's own pace with explanations.
“We observed administration of medicines and saw the registered nurse was talking with people with respect, explaining the reason for administration and supporting them to take their medicines at their own pace.” from the report
Building safety checks
Routine checks of the premises and equipment were being completed. Fire, gas, water, electrical and Legionella-related checks were recorded.
“Maintenance checks were routinely and thoroughly completed. Examples included fire safety, Legionella prevention, portable appliance testing, gas safety, water temperature checks and electrical safety.” from the report
Improved dignity
The previous breach about dignity and respect had been resolved. Relatives and professionals also reported improvements in staff interactions.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 10.” from the report
Unsafe medicines
seriousMedicine records had missing signatures, unclear recording of as-needed medicines and poorly maintained patch records. One person was given twice the prescribed as-needed dose.
“Medicines continued to be not managed safely. This placed people at risk of harm.” from the report
Poor risk management
seriousRisk plans did not explain clearly how risks should be reduced. Eight of 11 pressure-relieving mattresses checked were set more than 10kg away from people's weights.
“Of the 11 mattresses we checked, we found 8 to be in excess of 10kg different from people's weight.” from the report
Staffing and training
seriousRecruitment checks were incomplete, staff training and moving-and-handling assessments were not up to date, and staff deployment did not always provide timely support.
“The deployment and organisation of the staff team did not ensure people could be attended to in good time.” from the report
Food and fluids
seriousSome people could not reach drinks or call bells, one person waited an hour for a meal, and staff did not consistently offer suitable choices or support.
“People were at risk of malnutrition and dehydration.” from the report
Dementia-friendly environment
needs fixingThe home had not acted on the earlier recommendation. It lacked suitable visual and tactile features, accessible signage and enough suitable spaces for activities and visitors.
“The service has failed to take action to ensure that the premises and equipment is suitable.” from the report
Weak oversight
seriousThe provider's monitoring systems did not find or correct important problems. Incidents and accidents were not consistently investigated and lessons were not clearly recorded.
“These systems did not identify shortfalls in the quality and safety of the service or ensure that expected standards were met.” from the report
- 01What has changed since the inspection to make medicine records complete and ensure as-needed medicines are given and recorded correctly?
- 02How are you checking that each person's risks, pressure-relieving mattress settings and regular personal care are being managed safely?
- 03How many permanent and agency staff are on each shift, especially at weekends, and how do you check agency staff are inducted and competent before providing care?
- 04What action has been taken to ensure people can access drinks, meals and call bells promptly?
- 05What improvements have been made to the environment, activities and signage for people living with dementia?
This was an unannounced follow-up inspection covering all five key questions, including infection prevention and control under Safe, after a previous Inadequate rating and warning notice. This explanation was written from the published report of 23 February 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Heathlands Care Centre
3 rated inspections over a year: the service has improved, from Inadequate to Requires improvement.
- December 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2023Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2022InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2022
Registered with the Care Quality Commission on 19 April 2022.
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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