CQC report explained · a residential care home
What the CQC found at Heathside Retirement Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2021
Heathside Retirement Home was inspected but not rated; improvements were found, but the previous overall rating remains Requires Improvement.
This was a targeted follow-up inspection on 30 June 2021. One inspector checked whether the home had fixed problems with its quality checks and record keeping. The inspector spoke with people, staff and relatives, observed care, and reviewed care, medicines and management records.
Inspectors found improvements in risk assessments, night checks, medicines procedures and quality audits. The provider was no longer in breach of Regulation 17, which had been breached at the previous inspection.
This inspection did not give new ratings. The overall rating and the Safe and Well-led ratings remain Requires Improvement from the previous inspection. Effective, Caring and Responsive were not assessed in this targeted visit.
Risk management
People's risks and support needs were recorded, reviewed and available to staff. Incidents were also reviewed to reduce the risk of them happening again.
“Risk assessments and guidance to manage these risks were in place and regularly reviewed.” from the report
Medicines process
The medicines trolley was taken to the lounge, reducing the risk of tablets being dropped or staff being interrupted. The medicines review recommendations had been implemented.
“The provider had made improvements.” from the report
Quality checks
Monthly audits had become more robust. The home checked care plans, night records and medicines records, and staff had received further care planning training.
“Monthly audits were now more robust.” from the report
Clean environment and visiting
The home was visibly clean. Visiting arrangements used the conservatory and garden entrance, and testing arrangements were in place.
“The home was visibly clean throughout.” from the report
Masks were not always worn correctly
needs fixingSome staff wore their masks below their noses. The home said it would remind staff of the correct procedure.
“some staff weren't following government guidelines; with their masks being below their nose.” from the report
- 01How are you checking that all staff wear masks correctly when required?
- 02What evidence can you show that monthly care plan, night record and medicines audits are still being completed?
- 03How do you identify patterns in accidents and incidents, and what action do you take?
- 04When will the next comprehensive inspection assess Effective, Caring and Responsive as well as Safe and Well-led?
This was a targeted inspection of specific parts of Safe and Well-led, including infection control; it did not reassess the whole service, so the previous ratings remained in place. This explanation was written from the published report of 29 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, September 2020
Heathside Retirement Home was rated Requires Improvement; inspectors found staffing and medicines were generally safe, but risk records and management oversight were not reliable.
This was a focused inspection following concerns about risk management and quality checks. The inspection visit took place on 22 July 2020. The inspection activity ran from 20 July to 10 August 2020.
Inspectors looked only at Safe and Well-led. They found enough staff, safe recruitment, staff training for medicines and improved infection control. People and relatives said people felt safe.
However, some care plans and risk assessments did not reflect people's needs. One incident was not recorded correctly, and the management checks did not give a reliable overview of safety and care records.
The overall rating fell from Good at the previous inspection, published in August 2018, to Requires Improvement. The home breached Regulation 17 about good governance and must provide an action plan.
Enough staff
Inspectors found enough staff were on duty to meet people's identified needs.
“There were sufficient staff on duty to meet people's needs.” from the report
Medicines training
Staff who administered medicines had training and competency checks. The medicines administration records reviewed were completed correctly.
“The MARs we reviewed had all been correctly completed.” from the report
Infection control
The home had increased cleaning and provided handwashing facilities and protective equipment during the COVID-19 pandemic.
“Personal protective equipment was readily available for the staff team.” from the report
Staff support
Staff said managers were available to speak to them. Regular staff meetings and supervision meetings were held.
“Staff felt able to speak to the registered manager and regular staff meetings and supervision meetings were held.” from the report
Weak management checks
seriousThe quality assurance system did not give managers a clear picture of the service. Audits were not checked proactively and some records were not reviewed often enough.
“The lack of a robust quality assurance system giving a clear oversight of the service was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Care plans not always current
needs fixingOne person's care plan was not reviewed promptly after they moved in and did not reflect their support needs. Some staff also needed more support and training to write risk assessments and care plans.
“It had also not been reviewed a month after they moved to the home, in line with the home's policy, or audited.” from the report
Incident not recorded properly
seriousStaff did not recognise the seriousness of one incident. This meant it was not correctly recorded and the related risks were not fully assessed and managed.
“Staff had not considered it as a serious matter.” from the report
Medicines round arrangements
needs fixingStaff had to carry individual medicines up and down stairs because the trolley was on another floor. Inspectors recommended reviewing the process to reduce interruptions and the risk of dropping tablets.
“We recommend the process for completing the medicines round are reviewed to reduce the time taken and the risk of dropping tablets or being interrupted in the middle of administering a person's medicine.” from the report
- 01What changes have you made to ensure every person's care plan and risk assessment reflects their current needs?
- 02How do you now record, review and learn from incidents, including changes in a person's behaviour or support needs?
- 03How often is each person's care plan audited, and who checks that the audits lead to action?
- 04What has changed in the medicines round since the recommendation about carrying medicines between floors?
- 05What actions were included in the plan sent to CQC after the Regulation 17 breach, and what evidence shows those actions are complete?
This was a focused inspection of Safe and Well-led only, following concerns about risk management and quality assurance; Effective, Caring and Responsive were not assessed. This explanation was written from the published report of 16 September 2020 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 Heathside Retirement Home
4 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- July 2021Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- September 2020Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2015
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
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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