What the CQC found at Heron Hill Care Home

People described staff as kind and caring. Inspectors saw staff supporting privacy, dignity and independence.

“People were supported and treated with dignity and respect and involved as partners in their care.” from the report

People reported having plenty of choice and enough to eat and drink. Inspectors saw relaxed mealtimes and nutritional risks were assessed.

“People said the food was very good. They said there was plenty of choice and "more than enough" to eat” from the report

The home worked with doctors, specialist nurses and other health professionals. People's treatment wishes at the end of life were recorded.

“We saw from people's records that there was effective working with other health care professionals and support agencies.” from the report

The home had continued work to make the environment easier for people living with memory problems to understand and use.

“We saw the home had continued to develop a dementia-friendly environment to help maximise people's wellbeing and memory skills.” from the report

Inspectors found problems with administration records, controlled drugs and fridge temperature checks on some units. Some issues had not been found through the home's own audits.

“We found the management of medicines was not consistently good on all the units.” from the report

Two people had unexplained bruises that staff had not reported to management or the appropriate authorities. The concern was raised with the local safeguarding team during the inspection.

“However, during the first day of the inspection we found two people with some unexplained bruises that had not been reported by staff to the management or to the appropriate authorities.” from the report

The home had enough staff on the rotas, but agency staff made up a high proportion of shifts. On one unit, staff were sometimes not present and accessible in the dining area as required by risk assessments.

“On Cavell unit, there were periods of time when staff were not present and accessible to people in the dining area.” from the report

The activity coordinator and occupational therapist had left. Some people, including those nursed in bed or with limited communication, were at increased risk of social isolation.

“We found some people who were being nursed in bed or had limited communication were at increased risk of becoming socially isolated due to the current lack of person-centred activities provision.” from the report

Some care plans did not contain consistent or up-to-date information about people's needs and preferences. Some records were not dated, so it was unclear whether they were current.

“Not all the care plans we saw had been fully completed to reflect the individual's life story and personal preferences.” from the report

The home had no registered manager and the interim arrangement was not effective enough. Quality systems did not always identify problems quickly or maintain improvements.

“We found that management oversight on the three units had been inconsistent.” from the report