CQC report explained · a residential care home
What the CQC found at The Heathers
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found generally safe care, enough staff, effective infection control and safe medicines management. However, there were gaps in care records, emergency evacuation information and two medicines records.
- Effective?
- Good
- People's needs, nutrition and hydration were supported well. The service worked within the principles of the Mental Capacity Act and staff received relevant training and support.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its rating was not given in this report.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its rating was not given in this report.
- Well-led?
- Good
- Inspectors found effective leadership, useful audits, better care planning and an open culture. People and staff were more involved in care planning and service improvements.
What inspectors found, April 2023
Rated Good overall, but Safe Requires Improvement because inspectors found gaps in emergency information, care records and medicines records.
The inspection was unannounced and focused on Safe, Effective and Well-led. Inspectors spoke with 14 people, 12 staff and an advocate. They reviewed care records, medicines records, staff files and management records.
The home was clean and infection control was effective. There were enough staff, medicines were generally managed safely, and people were supported with food, drink, healthcare and decision-making. Inspectors found an open and friendly culture with visible senior staff.
Safe was rated Requires Improvement. Inspectors found some inconsistencies in care plans, inaccurate emergency evacuation information and two medicines that had not transferred to new records. The provider took immediate action, and the home was no longer in breach of regulations.
The overall rating improved from Requires Improvement to Good since the previous inspection. Effective and Well-led were rated Good, but the inspection did not assess Caring or Responsive.
Staffing and safeguarding
Inspectors found enough staff and consistent staffing levels. Staff understood safeguarding and people said they felt safe.
“There were enough staff to meet people's needs and requirements.” from the report
Infection control
The home was clean and had effective infection prevention measures, including appropriate arrangements for visitors and outbreaks.
“The cleanliness of the service had been improved and maintained with robust cleaning schedules and more domestic staff.” from the report
Food and healthcare
People's food and drink needs were met, and records showed good involvement from healthcare professionals.
“People's nutritional and hydration needs were met.” from the report
Leadership and improvement
The provider had acted on the previous inspection findings. Audits, electronic care records and team responsibilities were helping to drive improvements.
“The provider had completed a robust action plan in response to concerns raised at the last inspection and had complied with the requirements for the improvements.” from the report
Emergency evacuation information
seriousEmergency evacuation plans were not initially available in the emergency grab bag, and some online information was inaccurate. The provider corrected this during the inspection.
“Personal emergency evacuation plans were not in place in a grab bag in the event of an emergency.” from the report
Care plan records
needs fixingSome care plans did not consistently record sexualised behaviours. The manager said the information was updated immediately.
“We did see some inconsistencies regarding the documentation of some sexualised behaviours of people.” from the report
Medicine records
needs fixingTwo medicines from the previous recording cycle had not been transferred to new medicine administration charts. This was corrected immediately.
“For 2 people it was found that 2 medicines from the last cycle had not been transferred over to the new MARs chart.” from the report
Ongoing refurbishment
minorSome communal areas had improved, but inspectors said many areas still needed attention. The provider had an ongoing plan covering bedrooms and bathrooms.
“Many areas of the home still required attention.” from the report
- 01How do you now check that every person's emergency evacuation information is accurate and kept in the emergency grab bag?
- 02What checks are in place to make sure medicines transfer correctly when new medicine administration charts are started?
- 03How are care plans checked for complete and consistent information about behaviours and risks?
- 04Which parts of the refurbishment plan have been completed, and what work remains in bedrooms and ensuite facilities?
- 05How will you monitor the improvements made after the previous inspection?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and the report says the overall rating also used ratings from the last inspection. This explanation was written from the published report of 19 April 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, January 2023
The Heathers rated Requires Improvement; inspectors found serious problems with safety, medicines, consent and management.
This was an unannounced focused inspection. Inspectors visited on 12 and 21 September 2022. They spoke with 14 people, two relatives, seven staff and one health professional. They also looked at care records, medicines, staff recruitment files, the building and management records.
The home was not always safe. Risks such as choking, absconding and unsafe windows were not properly managed. Medicines records were incomplete and one person missed a critical medicine, causing harm. The building was run down, unclean and not always secure. Weekend staffing could also leave care staff stretched.
Care was not always effective or lawful. Care records did not always reflect people's needs, and there were no mental capacity assessments or best-interest decisions for people receiving restrictions. The home also did not provide enough specialist support for people's drug or alcohol misuse. Leadership and quality checks were not strong enough to identify and fix problems.
The overall rating changed from Good at the last inspection, published in March 2018, to Requires Improvement. The current inspection only directly reviewed Safe, Effective and Well-led. The other question ratings were carried forward from the previous inspection.
Food and nutrition
People's nutritional needs were met, including support with nutritional shakes where people had lost weight. People told inspectors they were happy with the food.
“People's nutritional needs were met, and people were happy with the choice of food.” from the report
Staff recruitment
The home carried out safe recruitment checks before employing new staff.
“Safe recruitment practices were followed. New staff had Disclosure and Barring Service (DBS) checks prior to employment.” from the report
Some medicines controls
Controlled medicines were stored safely, and body maps helped staff apply creams in the right places.
“Medicines including controlled drugs (medicines liable for misuse) were stored safely.” from the report
Infection control steps
Inspectors saw staff wearing masks correctly and found that visitors were supported to visit safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff support
Most staff training was up to date, and staff had received supervision and appraisals in the previous six months.
“Records showed staff had received supervisions and appraisals in the last six months and felt they could go to the manager with any concerns and for support” from the report
Missed critical medicine
seriousMedicine checks on admission were not safe. One person missed a critical medicine and suffered harm, leading to hospital admission.
“One person had not received a critical medicine resulting in harm.” from the report
Unmanaged choking risk
seriousA person with repeated choking incidents had no suitable risk assessment or guidance for staff. They were eating food they were known to choke on without supervision.
“One person had four documented incidents of choking on a range of foods, their nutritional care plan did not reference the choking risk” from the report
Unsafe premises
seriousThe building and equipment were worn, dirty and not always secure. Inspectors found issues including an insecure window restrictor where a person was at risk of jumping from a second-floor window.
“We found the premises and equipment were not clean, secure, suitable for purpose, or properly maintained.” from the report
Consent records missing
seriousThere were no mental capacity assessments or best-interest decisions for people receiving restrictive care practices. This meant care was not being delivered in line with the Mental Capacity Act.
“Mental capacity assessments and best interest decisions (BID) were not in place for anyone in the service.” from the report
Limited specialist support
needs fixingThe home did not use external agencies to help people manage or recover from drug or alcohol misuse. Many people said they had received no help with drinking, health or wellbeing.
“The service did not utilise support from external agencies to support people with managing or recovering from their drug and alcohol misuse.” from the report
Weekend staffing pressure
needs fixingStaff said weekend arrangements could leave one care worker supervising people alone while also helping with cooking. This made it harder to respond safely to incidents.
“on a weekend one care staff member could be left on their own to supervise people which is dangerous.” from the report
- 01What has been changed to prevent missed medicines, and how are medicine records now checked?
- 02How are choking, absconding, smoking and unsafe-window risks assessed and reviewed for each person?
- 03How are mental capacity assessments and best-interest decisions recorded when restrictions are used?
- 04What specialist support is now available for people who want help with alcohol or substance misuse?
- 05What extra staffing is provided at weekends, and how are incidents managed when staff are stretched?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 18 January 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.
Every inspection of The Heathers
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- April 2023Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2023Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- July 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Good
- September 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 24 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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