Heaton House Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

During our assessment of this key question, we found concerns around the management of people's medicines, the safety of the environment, and staff recruitment. You can find more details of our concerns in the evidence category findings below. People told us they felt safe, although agency staff did not know people as well as permanent staff. Medicines were not always managed safely. People were placed at risk of harm as some medicines processes were not fully embedded and effective. People did not always receive their medicines safely. Systems and processes introduced to make improvements to the environment following our last inspection had not been effective, and improvements had either not been made, or had not been sustained; this placed people at risk of harm. Fire safety checks were not always identifying issues, there were gaps both under and above fire doors, uneven flooring, loose cables and trip hazards between doors. The local authority told us they lacked confidence in how the providers' processes and systems were operated to keep people safe and felt some of the basic foundations were not always in place. Risk assessments in care plans varied in quality and detail, with some contradictory information noted. The electronic care planning system did not clearly separate out care plans and risk assessments and this information was often together on the same page. There was an absence in some people's care plans of robust best interests decision making; one care plan stated the person was unable to consent to care & treatment, however, the plan later stated the person had verbally consented to their care and treatment. Information regarding how to safely evacuate the premises was contradictory for one person. There was a lack of evidence of people being referred to other health and social care professionals.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider could not demonstrate staff were up to date with safeguarding training; the deputy manager said, "Staff have not done anywhere near adequate training. As things stand I can’t demonstrate staff are up to date with training." Staff we spoke with could not consistently evidence training, but did have some awareness of their role in safeguarding. The deputy manager told us they were responsible for the day-to-day running of the home, although the registered manager was also in the home on most days. Although training completion rates were low, staff we spoke with had an acceptable level of understanding regarding their responsibilities in relation to safeguarding; they told us they would report any concerns to the senior on shift or the deputy manager, who was responsible for escalating concerns to the local authority. The deputy manager knew what abuse was, and what they needed to report to the local authority in line with the local authority reporting procedures.

We saw staff were helpful and caring and appeared to have a good knowledge and understanding of the people they cared for. People spoke highly of the staff and felt they received a good standard of care. When people needed assistance to the bathroom, staff were fairly prompt and handled the situation proficiently and patiently, assisting some people into wheelchairs or into a hoist. At the lunchtime meal, staff were attentive and supportive and demonstrated care and patience. People told us they felt safe living at Heaton House, however, relatives had mixed views. One person said, "Yes, I feel safe, the staff are very caring, and they see you are safe." A second person told us, "I feel safe but a bit hemmed in, and I sometimes I feel everything is closing in on me." A relative commented, "I have sent a massive email to the safeguarding team about our concerns over [person name]; it has gone through to safeguarding at the local authority." Another relative said, "Yes, [person] is safe, I have no concerns at all."

Safeguarding processes were not robust. The deputy manager told us no safeguarding log was being used; this had also been identified through the local authority assessment and monitoring process. Instead of a safeguarding log, the deputy manager had been completing a safeguarding audit each month, which recorded the person's name, the date of the safeguarding referral, the issues raised, the action taken and the signed off date. These audits were completed up to November 2023, therefore we could not be certain if more safeguarding incidents had occurred, and the correct action taken. The registered manager had not completed any audits. People's care records were not completed to a consistently good standard and there were gaps in information to ensure staff provided safe care; the processes in place had not identified these gaps.

Staff showed us the electronic care planning system used. Care plans and risk assessments were often incorporated on the same page which presented the risk of staff not fully understanding how to support people safely. This was particularly relevant when agency staff were used, who were not as familiar with people as permanent staff. Staff were unable to demonstrate how people were involved in discussions about their care; a staff member told us, "If I have time to, I have a read in the care plan, so can find out [about people's likes and dislikes], or I talk to people. If I get any free time I will chat with people, the senior will tell me how to provide care." We asked the deputy manager if they were able to demonstrate any other ways in which people’s views and opinions had been sought, if they could evidence people had been involved in creating, reviewing and updating risk assessments, or how people had been involved in making decisions about their place of residence and care provided and the deputy manager said they could not. Staff feedback supported this.

Risk assessments varied in quality and detail, and contained some contradictory information. One person's care plan stated they were unable to consent to care & treatment, however, the plan later stated the person had verbally consented to their care and treatment. We found many examples where people's care plans were not fully completed, or not competed correctly. One person's care plan stated they required bite sized soft foods; however, records identified a number of foods had been consumed which should be avoided if on this diet type. This placed the person at risk of choking. We asked staff for a copy of the Speech and Language Therapy (SaLT) assessment for this person and staff confirmed they did not have a copy in the home, as the assessment had been completed when the person was in hospital. Staff confirmed they had not requested the assessment, nor any other information relating to this person’s dietary needs following the hospital assessment and told us they would request a copy of the SaLT assessment as a matter of urgency. One care plan identified the person needed assistance from 1 staff to guide them to safe exit point, in the event of an emergency evacuation. However, the plan then stated they would need the assistance of 2 staff to transfer and there was no instruction about where to go. Another person's care plan stated they required a pureed diet, and staff informed us this person's family had requested they be given a modified diet, due to issues with swallowing food. Staff confirmed neither SaLT nor the GP had been consulted about this. People and their relatives were not regularly involved in discussions about their care and support needs. Most people told us they had never seen their care plan and only 1 person told us they had; they said, "I have read it all, and it has been updated." One person's relative told us they could not remember seeing a care plan and another person's relative said, "We have been told about it but haven’t seen it."

The systems and processes in place did not assess or mitigate risks effectively. We asked the deputy manager for copies of all meetings with people and their relatives. We found there had been no meetings held since June 2023, which was the date of the previous inspection of Heaton House. We were provided with one set of minutes dated 07 February 2024, which had been attended by 2 people’s relatives. The deputy manager confirmed this was the only meeting which had been held. We asked the deputy manager for a copy of the equality and diversity policy relating to people living at the home, so we could assess how the provider ensured people’s protected characteristics were respected and supported. However, the policy provided to us specifically related to staff members employment rights and how these would be met. We asked if an equality and diversity policy was in place relating to the people being supported and the deputy manager told us the policy provided was the only one available.

The provider confirmed a place of safety and alternative temporary accommodation had not been arranged in the event of the need to evacuate the building. As a result, should an incident lead to the home not been temporarily habitable, there was currently nowhere for people to go. Staff told us they would look into identifying somewhere as a matter of urgency. Weekly fire drills were not completed consistently over the last 12 months but had become more consistent from November 2023, when a new maintenance person was employed; this indicated a lack of contingency plans to ensure contemporaneous records were maintained.

We identified a number of continued concerns with the environment. Environmental concerns included uneven flooring, raised areas which presented a trip hazard, fire doors not closing fully in the frame – internal checks of fire doors had not identified this, gaps under and around fire doors which would increase the risk of smoke inhalation. A fire risk assessment dated August 2023 had identified the current alarm system was not fit for purpose and a new system was required to be installed within 3 months; this had still not been done at the time of this on-site assessment visit. The fire risk assessment also stated issues with fire doors needed to be addressed immediately. The contingency plan and fire evacuation plan had no place of safety listed, only an initial meeting point. People's evacuation plans (PEEPs) lacked detail on the support people required to safely evacuate. The PEEPs file was also stored on the third floor in the office, which meant it would be inaccessible or time consuming to access in an emergency. The legionella risk assessment provided during this on-site assessment was out of date. However, an up to date risk assessment was shared as part of the factual accuracy process. The servicing of emergency lighting and the fire alarm system was last done by an external accredited provider in 2022. We were not assured the lift had an up to date and ‘proper’ safety certificate (LOLER) to ensure it was safe to use. Appliance cables located on the floor near to the front door also presented a trip hazard, as they had not been secured to the floor or wall. One person told us they had fallen over a door threshold and sustained injuries, however, there was no record of this person's fall within accident or incident records provided during the assessment.

The provider had failed to ensure premises and equipment were safe, properly and effectively maintained and suitable for their intended purpose, which placed people at risk of harm. There was a lack of contingency plans to ensure up to date environmental records were maintained. Following our last inspection, the provider submitted an action plan detailing how they would ensure improvements made to the environment were sustained. However, at this assessment we found systems and processes introduced had not been effective; improvements had either not been made, or had not been sustained. Water testing, to test for evidence of Legionella had not been carried out since September 2022. Although it is not a legal requirement to complete water testing, Health and Safety Executive guidance states Legionella monitoring should be carried out where there is doubt about the efficacy of the control regime or it is known that recommended temperatures, are not being consistently achieved throughout the system. Records we viewed on this assessment site visit showed recommended water temperatures were not being consistently achieved. As such, regular testing would be required.

The deputy manager told us staffing levels were already in place when they started employment at Heaton House, and these were what the provider continued to operate with. The deputy manager told us staff had not completed anywhere near enough training and had been given a year to get up to date. The provider could not demonstrate staff were up to date with required sessions; training data provided to us confirmed this. The deputy manager told us a new staff supervision process was introduced in 2024, which staff reported was being followed consistently, with meetings every 6 weeks or so. The deputy manager told us they were encouraging staff to sign up to the Disclosure and Barring Service (DBS) update system, but only a few had done so to date. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Where staff application forms contained very limited information on their employment history, this had not been explored at interview. Staff induction records did not specify what training was expected of inexperienced care staff or how the provider determined whether job applicants were competent and had the knowledge and skills to provide safe care. Providers should be able to demonstrate that staff have, or are working towards, the skills set out in the Care Certificate. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. The Care Certificate is made up of the 15 minimum standards that should be covered if staff are 'new to care' and should form part of a robust induction programme.

Staff recruitment was not robust, and staff were not always recruited safely. There was no dependency tool used to determine how many staff were required, based on people's individual and changing needs which placed people at risk of not receiving the appropriate level of staff support they needed. Completion rates of online training were very poor. New care staff, who had not worked in care previously, had completed limited training, and we were not assured the staff induction process was robust. One staff member was listed as having commenced the care certificate. The training matrix contained a mix of dates, for training staff had done, should have done or were scheduled to do, and therefore provided no assurance on completion rates. It was not clear what training the provider considered to be mandatory, to ensure people’s needs were being safely & effectively met. The training matrix showed very low completion rates in training which related to or was linked to the needs of people living at Heaton House. For example, none of the staff had completed training in end of life care or diversity & human rights. Staff training completion rates in dementia, diet & nutrition, safeguarding, and the mental capacity act and deprivation of liberty safeguards were extremely low, therefore we could not be assured staff had the necessary skills and knowledge to provide safe, effective, and responsive care to people. There was no evidence of staff supervision sessions being completed in 2023. We looked at 4 staff files; DBS certificates for 2 staff had the incorrect employer name listed on them. One staff member had started in employment 3 days before their DBS was requested by the provider. There was a lack of references for 3 of the 4 staff files we saw. Another staff member had supplied 2 references from previous employers, one of whom had not been in business for many years. There was no evidence the provider had attempted to validate these references or seek their own.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The deputy manager confirmed there were no risk assessments at the moment for flammable creams. A senior staff member told us they were waiting for the pharmacy to collect a controlled drug from 2023 as they were being returned. However, this was only written into the controlled drugs book retrospectively on day of the on-site assessment visit, after we had raised this with the deputy manager and a senior staff member to ensure there was an audit trail. Senior staff told us a new medicine started when a person was in hospital, and who had just returned to the location, had not been administered by agency staff as directed; staff had completed an incident form for this issue and handed to the deputy manager. A monthly medication audit completed by the deputy manager in February 2024 had identified a few issues; the deputy manager told us they picked up the same issues every month and more work was required to ensure medicines were managed safely. Care plans were in place for supporting people with diabetes, however, 2 staff did not have the full knowledge of a person’s plan on how to manage hypoglycaemia (low blood sugar); the only hypoglycaemic sign they described was ‘drowsiness’ and not the other symptoms listed in the person's care plan, which placed the person at risk. The same 2 staff told us there was training available via the on-line training provider in the management of diabetes, but they had not completed this.

We identified concerns with the management of people's medicines. We looked at medicines administered to 7 people and identified people were placed at risk of harm as some medicines processes were not fully embedded and effective. There was a missing protocol for 'as required' (PRN) medicines for one person who had been placed on end of life. This was a concern as a member of staff had wrote on the person's medicines administration records (MARs) 'not given as not agitated.' The medicine was not for agitation, it was for secretions. With no PRN protocol in place, the staff member was unsure what this medicine was for. Medicines were found in another person's dressing gown by their relative; we highlighted this to staff as this risk should have been identified in a risk assessment so that staff could make sure medicines had been taken; however, this was not seen. Staff were not recording people's drink thickeners regularly and this area needed improving. Another person was missing the times of paracetamol administration on 4 occasions. There were no risk assessments for flammable creams. We found a controlled drug from December 2023 in the controlled drugs cupboard, but this was not recorded in controlled drugs book. The provider had failed to ensure accurate and contemporaneous documentation and record keeping was being maintained in relation to the management of people's medicines.