We carried out a review of the data available to us about Heron Hill Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Heron Hill Care Home, you can give feedback on this service.
Heron Hill Care Home is a care home providing personal and nursing care to up to 86 people. The service provides support to older people and people who are living with dementia. The home is on three floors and arranged into three units. Nightingale is a general nursing unit on the ground floor. Cavell on the first floor is for people living with dementia and nursing needs. There is a small male only unit, Wheawall unit, accommodating up to 20 men on the second floor. All units have separate dining and communal areas. All bedrooms are single occupancy and have ensuite facilities. At the time of our inspection there were 72 people using the service.
People’s experience of using this service and what we found
People were safe and protected from abuse. There were enough staff, with the right skills, to support people. The provider used safe systems when new staff were employed. Risks to people were identified and managed. Staff followed systems and processes to safely administer, record and store medicines. Regular checks were completed to ensure that should any shortfalls be identified they could be promptly addressed. The registered manager had systems to learn and share lessons from incidents. People were protected against the risk of infection.
People received the support they needed because staff were trained in how to provide their care. Most people were positive about the meals provided. Some people raised concerns about the choice and variety of meals. The registered manager addressed this during the inspection. People’s rights were protected. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Staff planned and provided care to meet people’s needs. People were provided with a variety of activities they enjoyed. One person said, “There is lots to do if you want.” The provider had a procedure for receiving and managing complaints about the service. People received support, as they needed, as they reached the end of life.
People told us the service was well managed and said they would recommend it. The registered manager was committed to providing people with person-centred care. People were asked for their views and their feedback was used to further improve the service. Staff felt well supported and able to provide good care to people. The registered manager and staff worked in partnership with other services to ensure people received the care they needed.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and/or who are autistic.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection: The last rating for this service was requires improvement (published 4 April 2019).
At our last inspection we recommended the provider made improvements to medicines management, capacity assessments, activities and managing records. At this inspection we found the provider had made the required improvements.
Why we inspected
This inspection was prompted by a review of the information we held about this service. We identified the service may have improved since the last inspection. We carried out a focused inspection to review the key questions of safe, effective, responsive and well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Heron Hill Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Heron Hill Care Home provides personal and nursing care for up to 86 people. The home is on three floors and arranged into three units. Nightingale is a general nursing unit on the ground floor, Cavell on the first floor is for people living with dementia and with nursing needs. There is a small male only unit, Wheawall unit, accommodating up to 20 men on the second floor. All units have separate dining and communal areas. All bedrooms are single occupancy and have ensuite facilities. At the time of our inspection there were 67 people living in the home.
People’s experience of using this service:
•We found that there were systems for assessing and managing risk but these were not always monitored to make sure the system was being as effective as it could be. Aspects of medicines management had not been monitored to make sure staff were following the correct procedures and that lessons learned were being disseminated to all staff. We have made recommendations about this.
•The service did not have a registered manager in post. The registered provider had acted quickly to put an interim manager in post to try to provide continuity following the unexpected loss of the previous registered manager. This appointment did not appear to have been effective and we found management oversight had been inconsistent.
•The provider had safeguarding systems in place and staff received training on this. We noted two instances of unexplained bruising that had not been reported to the management team. To help make sure safe practices were being used to reduce the risk of any bruising an occupational therapist reassessed people with specific moving and handling needs to help reduce this risk.
•High numbers of agency staff were being used to maintain safe staffing levels. The registered provider was actively recruiting and several new care staff were due to start following security checks. There was sufficient staff on the rotas to support people but some people were not always monitored by staff in line with their risk assessments to ensure their safety. The service was engaged in recruiting permanent staff and had thorough recruitment process to help ensure new staff were suitable to work with the people who lived at Heron Hill Care Home
•The registered provider had procedures for assessing a person's mental capacity in line with the Mental Capacity Act 2005. However, we found some inconsistencies in the recording of some people’s capacity assessments and some restrictions placed on them. We have made recommendation about this.
•Some staff training was overdue for staff including medication competencies. The management training analysis had identified some staff needed updates on training. The training plan covered the required training and was scheduled and organised to take place within the next two weeks.
•Everyone who lived at Heron Hill Care Home had nutritional risk assessments completed to identify their needs and any risks and people had been appropriately referred to their GP or to a dietician. However, we noted some supplementary records of food and fluids taken were not always being completed accurately to ensure accurate records. Some records we looked at had not been dated, so it was unclear if they were up to date. We have made a recommendation.
•A limited range of activities were available at the time of the inspection. We found some people who were being nursed in bed or had limited communication were at increased risk of becoming socially isolated. We have made a recommendation.
•Risk assessments relating to the environment were in place and to provide guidance and support for staff to provide appropriate care.
•Staff employed were supplied with personal protective equipment for use to prevent the spread of infections. Staff had received training in infection control.
•People were supported to maintain their independence. Staff took appropriate actions to protect people's dignity and privacy.
•People knew how they could complain about the service provided. The provider had a procedure for receiving and responding to complaints about the service. Complaints received had been investigated and responded to in line with the provider's procedure.
•People said staff were kind and caring. People told us staff were polite and willing to listen to them and help them, if they had a problem.
•We saw from people’s records that there was effective working with other health care professionals and support agencies.
•We saw people's treatment wishes, in consultation with their families, had been made clear in their records about what their end of life preferences were and where and how they wanted to be supported.
Rating at last inspection: Requires Improvement. (Report published 6 February 2018)
Why we inspected: This was a planned comprehensive inspection based on the rating from the previous inspection.
Follow up: We will continue to monitor this service and plan to inspect in line with our reinspection schedule for those services rated Requires Improvement. We may inspect sooner if we receive information of concern.
Following our inspection in April 2017 the provider developed a plan to make improvements to the service. During our inspection in November 2017 we found the provider had taken action to improve the quality and safety of the service. However we found further improvements were required to ensure people consistently received safe and effective care.
This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.
Heron Hill Care Home, (Heron Hill), is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Heron Hill provides accommodation and personal and nursing care for up to 86 people. The home is on three floors and arranged into three units. Nightingale is a general nursing unit on the ground floor and Cavell and McKenzie on the first and second floors care for people with dementia nursing needs. All of the units have separate dining and communal areas. All bedrooms are single occupancy and have en suite facilities. At the time of our inspection there were 64 people living in the home.
There was a manager employed at the service. The manager had applied to us to be registered. The manager’s application for registration was approved after we visited the service in November 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People were safe living in the home. They were protected from abuse and hazards to their safety had been identified and managed.
Improvements had been made to how medicines were managed and people received their medicines safely and as they required.
The premises and equipment were safe for people to use. Procedures were in place to protect people in the event of a fire.
People enjoyed the meals provided and were protected against the risk of unplanned weight loss. People received the support they needed to enjoy their meals. We discussed improving how meal choices were communicated to people living with dementia.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. We have made a recommendation about consent for the use of equipment.
Care was planned and provided to meet people’s needs. Some care records held inconsistent information or had not been fully completed. However, the staff knew the support individuals required and provided this. We have made a recommendation about managing records.
People were protected against the risk of infection. We identified one issue where staff were unclear about if an item of equipment could be used by more than one person. We have made a recommendation about guidance for staff around use of equipment.
There were enough staff to support people. The provider assessed staffing levels taking account of people’s needs. The home provided nursing care and there were qualified nurses employed on each unit.
Although safe systems were used when new staff were employed, we found the checks carried out on new staff needed to be more robust. This was addressed during our inspection.
People’s needs were assessed to ensure they received the support they required. Appropriate specialist services had been included in assessing people’s needs and planning their care. Some records were unclear about how people had been assessed for the use of specialist seating. We have made a recommendation about the use of some specialist equipment.
Staff received training and support to ensure they had the skills and knowledge to provide people’s care.
The staff supported people to access prompt health care from local services as they required.
The premises were purpose built to provide accommodation for people who required personal and nursing care. Accessible signs were used to assist people to locate communal areas and their own rooms. Further improvements were planned for the areas where people living with dementia were accommodated to enhance their wellbeing.
The staff treated people who lived in the home and their families in a kind and caring way. Visitors were made welcome and people could see their friends and families as they wished. The staff knew people they were supporting well. They took time to spend with people and provided support promptly and patiently if people were anxious.
People were supported to maintain their independence. The staff took appropriate actions to protect people’s dignity and privacy.
People knew how they could complain about the service provided. The provider had a procedure for receiving and responding to complaints about the service. Complaints received had been investigation thoroughly and responded to in line with the provider’s procedure. Where concerns identified areas of the service that could be improved the manager had taken action.
Processes were in place to ensure people received appropriate support as they reached the end of their life. People had been asked for their wishes and the manager had ensured any decisions relating to the use of cardiopulmonary resuscitation were clear and correctly recorded.
There were appropriate arrangements for the management and oversight of the service. The provider and manager had worked with external stakeholders to make the required improvements to the service. The manager worked cooperatively with external bodies and shared important information as required.
The systems used to monitor the quality of the service had improved. Although we found areas that required further improvement the provider was meeting the requirements of the regulations.
During this inspection we reviewed the action taken by the provider to meet the requirements of the regulations, these included; safe care and treatment, including medicines management. Person-centred care. Need for consent. Safeguarding service users from abuse and improper treatment. Premises and equipment in relation to infection control and environment maintenance. Good governance and staffing.
At this inspection we found the provider was still in breach of the regulatory requirements for safe care and treatment, including the proper and safe management of medicines. Person-centred care. Need for consent. Safeguarding service users from abuse and improper treatment. Good governance and staffing.
We found that the provider had made some improvements, which are included in the main body of this report. The provider was no longer in breach of Regulation 15 in relation to premises and equipment.
The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. The purpose of special measures is to:
Ensure that providers found to be providing inadequate care significantly improve. Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made. Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.
Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider's registration to remove this location or cancel the provider's registration.
Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is over three floors and has three separate units. Each unit has a separate dining area and communal lounge. On the ground floor Nightingale Unit provides general nursing care; on the first floor Cavell Unit provides nursing care for people living with dementia and on the second floor McKenzie Unit provides care for males living with dementia.
There is a hair dressing room in the service. All bedrooms are of single occupancy and have ensuite facilities. The service provides support to adults who have a physical disability, mental health needs, behavioural support needs, dementia and complex nursing needs. One unit is a 20 bedded all male unit, for those who may present more challenging behaviours that need specialist input. At the time of the inspection there were 76 people living at the service.
There was a newly appointed manager in place who had applied to become a registered manager. The manager had been promoted from deputy manager and was being supported by the nominated individual during their induction period. The manager had submitted their application to CQC to become Registered Manager.
A Registered Manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
A Nominated Individual is a person who has registered with the Care Quality Commission and must be employed as a director, manager or secretary of the organisation with responsibility for supervising the management of the regulated activity.
The manager and nominated individual were available throughout the inspection and received verbal and written feedback.
People told us they felt safe at the service and with the staff who supported them. The service had procedures in place for dealing with allegations of abuse. Staff were able to describe to us what constituted abuse and the action they would take to escalate concerns.
Staff members spoken with said they would not hesitate to report any concerns they had about care practices.
On the third day of the inspection we found examples of people being deprived of their liberty. For example, one person was being assisted with personal care on a daily basis, due to their resistance to care support. Staff told us they had to use low level restraint, also known as safe holds during personal care interventions. The restrictive practice had not been formally risk assessed or care planned and a DoLS application had not been submitted. This meant that the person was being unlawfully restrained. We looked at a DoLS urgent authorisation for the same person in relation to a secure environment. The authorisation had expired in 2015 and was still held on the person’s care records. This meant that the person was at risk of being unlawfully restricted.
After the inspection the manager provided us with information following a full audit of restrictive practices at the service, a further 26 DoLS applications had been submitted, due to people living within a secure environment and or resisting personal care interventions.
We found the provider to be in breach of regulation 13 of the Health and Social Care Act 2014, safe guarding service users from abuse and improper treatment.¿
We received feedback from the local safeguarding team within Cumbria County Council who told us that the provider had continued to raise safeguarding referrals and had been responsive to actions set by the safeguarding team to protect service users involved.
People’s needs were not always risk assessed against avoidable harm and injury. Care records showed general risk assessments had been completed. However, person centred risk assessments had not always been undertaken; for example, when people were at risk of choking or aspirating. This placed people at significant risk of harm.
One person’s care records showed that they had not been adequately risk assessed following two falls. Their care plan for falling had not been updated to show how they would be supported and monitored to prevent further incidents, which could cause harm and personal injury. Another person’s care records stated that they required a soft diet; when we visited the person in their bedroom we found that they had been given chicken, hard boiled potatoes and carrots. This meant that the person was at risk of choking. We informed the manager immediately and action was taken to provide the person with the correct meal type.¿
This meant that the provider continued to be in breach of Regulation 12 of the Health and Social Care Act 2014, safe care and treatment in relation to personal risk assessment.
The care records we looked at showed that pre-admission and admission risk assessments and care planning had improved since the last inspection.
The environment was clean and well maintained. We found that infection control systems had improved and were being monitored by the manager. This was an improvement since the last inspection.
The manager showed us plans for replacement of corridor flooring on the McKenzie Unit. After the inspection we were sent a risk assessment from the provider in relation to planned arrangements to ensure the safety of people who lived at the service during the replacement of flooring. The manager updated us on 11 May 2017 and confirmed that the work was nearly completed and some service users had been moved during the day to Cavell Unit to provide a safe environment.
On the first day of inspection we looked at bedrail safety. We found that all bedrail bumpers were in place with the exception of one. Action was taken immediately by the manager. On the third day of our inspection we checked all bedrails used at the service; we found that all bedrails had bumpers. This was an improvement since the last inspection. Bedrail bumpers prevent injury and entrapment for people that require bedrails whilst in bed.
On the first day of the inspection we informed the manager that a sluice had been left unlocked on the Nightingale Unit. Action was taken to lock the sluice. On the third day of the inspection we found that the sluice was again left unlocked. This placed people at risk of personal injury. Sluice areas are prohibited for people that live at the service, due to risk of exposure to chemicals and clinical waste.
On the first day of the inspection we looked at the provider’s fire risk assessment undertaken by an independent company on 22 February 2017. The fire risk assessment identified four areas that required action to be taken within 1-5 days. High risk areas had not been addressed, these included removal of combustible materials from the electrical room and plant room. This placed people at immediate risk of harm. We informed the nominated individual who took action and areas of hazard were cleared immediately.
This meant that the provider was in breach of Regulation 12 of the Health and Social Care Act 2014, safe care and treatment in relation to premises safety.
We found that staff recruitment was safe and staff were supported throughout their
At that inspection we found a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities Regulations) 2014 regarding the proper and safe management of medicines. We found that medicines were being not stored safely during medicines rounds and administration was not recorded correctly. We asked the provider to take action to make improvements. The registered provider gave us an action plan telling us how they were going to make the improvement by 31 October 2015.
There was also a breach of Regulation 9 (person centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because records for the management of medicines and creams did not contain sufficient detail to make sure that people received appropriate care. At this inspection we found that this had improved. Some people were prescribed emollient creams that were applied by carers when they helped people wash and dress. We looked at seven people’s records and found that carers were applying creams regularly
Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is over three floors and has three separate units and each unit had separate dining and communal areas. On the ground floor, Nightingale unit provided general nursing care, on the first floor, Cavel unit provides nursing care for people living with dementia and on the second floor is McKenzie an all male unit.
There is a hairdressing room in the home. All bedrooms in the home are for single occupancy and have ensuite facilities. The service provides support to adults who have a physical disability, mental health needs, behaviour support needs, dementia and complex nursing needs. One unit is a 20 bedded all male unit, for those who may present different or more challenging behaviours At the time of the inspection there were 78 people living in the home.
At this inspection 5 and 6 December 2016, we found that some improvements had been made to aspects of medicines management. However, the medicine storage and medicines monitoring that could have an impact on people living in the home continued to require improvement. This was a continued breach of Regulation 12 (safe care and treatment) of The Health and Social Care Act 2008 (Regulated Activities Regulations) 2014.
We found there were several other breaches of the regulations that could have an impact on the people who lived there. There was a breach of Regulation 15 regarding premises and equipment, a breach or Regulation 11 - Need for consent and of Regulation13 - safeguarding service users from abuse and improper treatment. There was a breach of Regulation 18 - Staffing, Regulation 9 - person centred care and Regulation 17 - Good Governance.
The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:
Ensure that providers found to be providing inadequate care significantly improve
Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.
Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.
At the time of this inspection the service did not have a registered manager in post. The previous registered manager had left the month before. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We saw that the staff on duty approached people in a friendly and informal way. People told us that the staff were “kind” and “lovely”. Relatives we spoke with during the inspection whose family members lived at Heron Hill Nursing Home told us they felt that the staff were caring and that they treated their family members with dignity and respect.
We found that a range of information and leaflets were available for people in the home and their relatives to help inform their choices. This included information about support agencies such as Age Concern, financial help and advocacy services that people could use. An advocate is a person who is independent of the home and who can come into the home to support a person to share their views and wishes if they want or need this.
We saw that care plans were being reviewed and updated. For example, changes in a person’s weight or their continence needs that needed to be followed up with other agencies. Care plans we looked at contained nutritional assessments and saw a check was being done on people’s weight to monitor for changes. People told us the food in the home was “good” and that they had a choice of food and drinks. We saw that if someone found it difficult to eat or swallow advice had been sought from the dietician or the speech and language therapist (SALT).
Some care plans that had not been completed with information on specific risks and behaviours. We have made a recommendation that the service seek guidance about developing with people a personalised care management plan so staff can take a person centred approach to care provision. We found that there were opportunities for people to participate in organised activities in the home but this was not always being effectively tailored to specific needs.
The home had systems to check information when new staff were recruited and all staff had appropriate background checks before starting work to help make sure they were suitable for the role. Training was being provided to staff on the safeguarding of adults who may be vulnerable due to their condition.
We noted during the inspection that contractual arrangements were in place for staff. These included disciplinary procedures to support the organisation in taking immediate action against staff in the event of any misconduct or failure to follow company policies and procedures. We could see that the deputy manager had been contacting staff to give them timescales in which to do the e learning and had issued internal ‘improvement notices.
The service used a dependency tool to help them assess staffing needs against the level of need and dependency of the people living there. We noted that the dependency assessments did not present as being consistent in staffing for identified levels of need around the nursing staff. This was because there were not sufficient permanent registered nurses to increase numbers across all shifts should needs change and more nurses be needed quickly. There was no indication of contingency planning for cover on the units should these core nursing staff be off sick or on leave. We have made a recommendation that the registered provider reviews the staffing to make sure they can respond to nursing staff shortages and make sure they can respond quickly to changing nursing needs.
We observed that there was a complaints procedure displayed throughout the home for reference and information. We saw that resident and relatives meetings had taken place. These were used to share news and information within the home and to get people’s views and ideas that might improve the quality and safety of the service. Relatives and people who lived in the home said that their views about the service were being sought.
You can see what action we told the provider to take at the back of the full version of the report.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Heron Hill Care Home on our website at www.cqc.org.uk.
Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is on three floors and has four separate units each with separate dining and communal areas. All bedrooms are single occupancy and have en suite facilities. The service provides support to adults who have a physical disability, mental health needs, behaviour support needs, dementia and complex nursing needs.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
We found on the day of our inspection 20 December 2016 and from looking at rotas and speaking to staff that staff levels fluctuated in the home and staff were at times being moved to work on different units with people whose needs they were not familiar with. We found that efforts were being made to recruit more permanent staff and that agency staff were used to maintain sufficient numbers of staff but that the skills and experience of people were not always being taken into account when staffing units. Work that had been done on using a dependency tool to assess and adjust staffing levels but the staffing was not consistent and stable across the home and the numbers of permanent staff were sometimes exceeded by agency staff on night shifts.
Rotas over the Christmas period indicated that all the units would have sufficient nursing and care staff on duty as long as all staff worked their shifts. On the day we visited sickness had reduced the staff levels and also the adverse weather conditions. There was no clear contingency in place and we recommend that the service finds out more about developing procedures for dealing with emergency situations when staffing levels drop below the accepted level which is likely to have an impact on care.
This unannounced inspection of Heron Hill Care Home took place over three days on 17, 20 and 21 July 2015. During our previous inspection visits on 21 and 22 October 2014 and 11 May 2015 we found the service was not meeting all the regulations.
This was because at our inspection on 21 and 22 October 2014 there was not verifiable evidence that all staff in the home had received induction training, appropriate training for their roles or regular supervision and appraisal to monitor their performance. People living there could not be sure the staff caring for them had received appropriate training and supervision to meet their needs.
We also found at that inspection that people were not being protected against the risk of unsafe care because the registered provider had not made sure that all aspects of service provision and record keeping were being regularly monitored for effectiveness. We issued requirement notices to the provider that required them to make improvements in relation to staff training and supervision and the effective monitoring of records and service provision. The registered provider wrote to us and gave us an action plan saying how and by what date they would make the required improvements. They also told us how they would monitor this.
We also carried out an inspection 11 May 2015 following concerns raised by agencies and individuals regarding low staffing levels within the home. At this inspection we found that the registered provider did not have effective systems to ensure they consistently deployed sufficient numbers of suitably qualified and skilled staff to make sure that people’s care and treatment needs were always met. We issued a requirement notice that required them to make improvements in relation to this.
At this inspection17, 20 and 21 July 2015 we found that the registered provider had made the improvements needed to meet the requirement notices from the previous visits. However at this inspection we found that there was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities Regulations) 2014 regarding the proper and safe management of medicines. We found that medicines were being not stored safely during medicines rounds and administration was not recorded correctly. We found that care plans for the management of medicines and creams did not contain sufficient detail to make sure that residents received appropriate care.
You can see what action we told the provider to take at the back of the full version of the report.
Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is over three floors and has four separate units and each unit had separate dining and communal areas. All bedrooms in the home are for single occupancy and have ensuite facilities. The service provides support to adults who have a physical disability, mental health needs, behaviour support needs, dementia and complex nursing needs. During the period of the inspection there were 67 people living there.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We spoke with people in their own rooms and those who were sitting in the communal areas and were told by people that they felt the standard of care was satisfactory. The home had moving and handling equipment and aids to meet people’s mobility needs and to promote their independence. The home was being maintained and we found that all areas were clean and free from unpleasant odours.
We found that there was sufficient staff on duty to provide support to people to meet individual’s personal care needs. Staff had received training relevant to their roles and were supported and supervised by the registered manager and the care manager. The home had effective systems when new staff were recruited and all staff had appropriate security checks before starting work. The staff we spoke with were aware of their responsibilities to protect people from harm or abuse.
The service had worked well with health care professionals and external agencies such as social services and mental health services and the Care Home Education and Support Service to provide appropriate care to meet people’s different physical, psychological and emotional needs.
The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves.
People were able to see their friends and families as they wanted and go out into the community with support. There were no restrictions on when people could visit the home. All the visitors we spoke with told us that staff were “friendly”.
People had a choice of meals and drinks. People who needed support to eat and drink received this in a supportive and respectful manner. We saw that people were supported to maintain their independence and control over their lives as much as possible.
There were quality monitoring systems in place and being used to assess and review the quality of the services provided.
We carried out an unannounced comprehensive inspection of this service on 21and 22 October 2015 at which breaches of legal requirements were found that had an impact on people living in the home. This was because the registered provider had not always made sure there was the right mixture of staff skills and experience on all shifts or that training and staff support was monitored so people could be sure staff had the right skills and experience to support them.
Following the comprehensive inspection , 21and 22 October, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. They sent us an action plan setting out what they would do to improve the service and meet the requirements in relation to the breaches and when this would be completed
After that inspection, 21and 22 October, we received concerns from other agencies and individuals in relation to the levels of suitably qualified staff being deployed in the home to meet people’s needs and to provide individual support where it was needed. As a result we undertook a focused inspection on 11 May 2015 to look into those concerns. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Heron Hill Care Home on our website at www.cqc.org.uk
Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is on three floors and has four separate units each with separate dining and communal areas. All bedrooms are single occupancy and have en suite facilities. The service provides support to adults who have a physical disability, mental health needs, behaviour support needs, dementia and complex nursing needs. At the time of our visit there were 66 people living in the home.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
We found on the day of our visit, 11May 2015, that there was an adequate level of staff on duty to meet minimum requirements. However the evidence we saw indicated that this level of staffing was not always being maintained as nursing staff levels were not consistent across all units that required nursing support and leadership. This meant the levels of care support people received was inconsistent.
We also noted that one to one support provided to people assessed as needing this was not consistent either with different staffing arrangements on different units. This meant that some people might not get the level of individual support and supervision they had been assessed as needing.
We found that staff and the registered manager were working hard to try to maintain a safe service and to recruit and retain suitable staff. We could see that the use of agency staffing was decreasing and the registered manager anticipated that within a period of weeks there would no longer be a need to use agency support staff as new staff started.
You can see what action we told the provider to take at the back of the full version of the report.
This unannounced inspection took place over two days on 21 and 22 October 2014. During our previous inspection visits on 22 July, 9 August and 10 September 2014 we found the service was not meeting all the regulations we looked at. This was because the registered provider did not have appropriate arrangements in place to manage and monitor medicines safely, was not ensuring that the premises were being well maintained and that premises and equipment were kept clean and hygienic to reduce the risk of infection.
We took enforcement action and issued three warning notices to the provider that required them to make immediate improvements in relation to the way medicines were managed and monitored. The warning notices also required them to make improvements to the environment, equipment and infection control to protect people living at the home.
The registered provider wrote to us and gave us an action plan saying how and by what date they intended to improve the premises, infection control and the way medicines were managed. The registered provider also gave us a voluntary undertaking to take no further admissions whilst they addressed the breaches. At this inspection on 21 and 22 October 2014 we found that the registered provider had made the improvements needed to meet the requirements of the warning notices and compliance actions from the previous visits. However at this inspection we found that there were others breaches of regulations that had an impact on people living in the home.
Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is on three floors and has four separate units each with separate dining and communal areas. All bedrooms are single occupancy and have ensuite facilities. The service provides support to adults who have a physical disability, mental health needs, behaviour support needs, dementia and complex nursing needs.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
We found that there were adequate numbers of staff to provide support to people to meet basic care needs but the registered provider had not always made sure there was the right mixture of staff skills and experience on all shifts to meet assessed needs and behaviours. We also found that training and staff support was not being well monitored or recorded so people could be sure all staff had the right skills and experience to support them.
We found that records of what staff training had taken place and staff supervision were not up to date. We saw that staff working with people whose behaviour may challenge the service were not being enabled to access accredited training relevant to their workplace and role. This meant that people could not be sure that staff always had the right training to carry out their roles effectively.
There were limited organised activities provision available to people. We found that reductions in the activities staff meant that people were not regularly being given the opportunity to have support to follow their own interests and to take part in organised activities with others. This could affect their social inclusion.
The systems used to assess the quality of the service had not identified all the issues that we found during the inspection. Whilst we found that some aspects of the quality monitoring processes were being done well others, such as monitoring staff training.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to making sure staff always had the right skills, competencies and knowledge to meet the needs of people who used the service. The registered provider had not made sure that all staff in the home had received induction training, appropriate training for their roles or regular supervision and appraisal to monitor their performance. We also found that people were not being protected against the risk of unsafe care because the registered provider had not made sure that all aspects of service provision were being regularly monitored for effectiveness. You can see what action we told the provider to take at the back of the full version of this report.
We found that people living at Heron Hill Care Home were able to see their friends and families as they wanted. There were no restrictions on when people could visit them. We could see that people made day to day choices about their lives in the home and were able to follow their own faiths. People living there and visiting relatives told us that staff were polite and caring and “Worked very hard”.
The premises and equipment were being well maintained for the people living there. People’s needs had been assessed and care plans developed. There were suitable hoists and moving aids in use in the home to assist with the different mobility needs of people living there.
Staff had liaised with other healthcare professionals to make sure specialist advice was available to people for the care and treatment they needed. Medicines were being administered and recorded appropriately and were being kept safely.
Care records contained information about the way people would like to be cared for at the end of their lives. There was information which showed the provider had discussed with people if they wished to be resuscitated. The service had policies in place in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).
The home had effective systems when new staff were recruited and all staff had appropriate security checks before starting work.
We considered our inspection findings to answer the questions we always ask:
' Is the service safe?
' Is the service effective?
' Is the service caring?
' Is the service responsive?
' Is the service well-led?
This is a summary of what we found. If you want to see the evidence that supports our summary please read the full report.
Is the service safe?
Before our visit we received information that at times staff levels had been low so that staff might not have time to give appropriate and effective care to people. We made two unannounced out of hours visits to check on staff levels.
We saw there were adequate levels of nursing and care staff on duty at the times of our two visits. Agency staff were also working in the home to help ensure that an adequate level of care and nursing staff was maintained. At times the numbers of agency staff was high, especially on night duty. However the agency staff had been working in the home for some months and so had become more familiar with the service and people living there.
Is the service effective?
We found that the provider was actively recruiting staff to increase the number of permanent staff employed in the home. This would reduce the need to have agency staff.
Is the service caring?
From our observations during the two visits we saw that staff were respectful and gave encouragement and prompting when supporting people. For example we observed positive staff interactions with people taking their tablets, eating and having their drinks.
Is the service responsive?
We observed that a member of agency staff had been brought in to provide additional observation for a person who had injured their head. The staff were monitoring their condition.
We observed that night staff were predominately male. This meant that the choice for people to have only female carers at night, should they prefer that, was not possible.
Is the service well-led?
The staffing levels in the home had been reduced and at times low. In response to this the provider had put interim contingency actions in place. This included using agency staff in the short term to maintain better staffing levels, extra overtime shifts for permanent staff and an on going recruitment drive.
Below is a summary of what we found. The summary is based on our observations during the inspections, discussions with staff, looking at supplies of medicines and looking at records.
During this inspection we checked if compliance actions we made at the last inspection in April 2014 had been completed. We also looked at outcomes in response to concerns raised with us that one or more of the essential standards of quality and safety were not being met.
We considered our inspection findings to answer the questions we always ask:
' is the service safe?
' Is the service effective?
' Is the service caring?
' Is the service responsive?
' Is the service well-led?
This is a summary of what we found. If you want to see the evidence that supports our summary please read the full report.
Is the service safe?
CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We looked at the records of two applications that had been made. These had been correctly submitted and were in order. The service had appropriate policies and procedures in place in relation to this and also regarding the Mental Capacity Act 2005.
At our visit in April 2014 we found that the provider did not have a robust recruitment procedure in practice. The recruitment records we viewed during this inspection had all of the information required to show that a variety of checks of suitability had been completed. This would help to ensure that people being employed were of good character, physically and mentally fit for the work and had the right qualifications or skills and experience.
Before our visit we received information that at times staff levels had been low so that staff might not have time to give appropriate and effective care to people. We made two visits to check on staff levels. There were adequate levels of nursing and care staff on duty at the visits. Agency staff were working in the home because the provider had identified there was a shortage of care and nursing staff. We asked the manager to provide us with information on the staff establishment, the rotas, staff levels, deployment and recruitment updates on a two weekly basis. This was to monitor the interim staffing arrangements in place.
We found that the service was not safe because people were not protected against the risks associated with use and management of medicines. People did not always receive their medicines in a safe way. Medicines were not administered and recorded appropriately.
We found that maintenance and redecoration work that we had been told would be taking place had still not been attended to in the communal areas and corridors of the home. This meant that people living at Heron Hill did not have a well maintained, home that was easy to keep clean and hygienic. Communal areas and the lounge furnishings did not provide pleasant environments to spend time in.
Equipment in the home was being maintained under service contracts. The records of how or when the items had been cleaned and visually checked by staff were not up to date or present in some cases. We could see that there were various marks and discoloration, accumulations of dust and some staining on the hoists, bath aids, wheelchairs and sitting weighing machines we examined. This indicated that equipment was not being cleaned and checked to make sure it was clean and ready to use.
Is the service effective?
We found that care plans for managing medicines were poor and staff did not have clear guidance available to them to make sure that people received appropriate care.
Visitors we spoke with confirmed that they could visit anytime. They also told us they could see their relatives in private in their rooms as well as communal areas.
We found that mobility equipment was in place and people had been assessed for its use. The equipment and how it was to be used was set out in people's care plans.
During our inspection it became evident that the systems being used to monitor the quality of the services provided were not being effective. We found that the system of checks or 'audits' being used by the service as part of their quality monitoring were not always robust and fully effective. For example, environmental defects had not been acted upon and medicines practices were not being effectively monitored.
Is the service caring?
We observed that staff were respectful and gave encouragement and prompting when supporting people, for example with meals and drinks.
People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.
Relatives told us the staff 'Come very quickly when he needs them'. We were also told that the staff had been 'Brilliant' with their relative.
Is the service responsive?
Relatives we spoke with told us that staff listened to them and kept them informed of any changes in their relative's needs. We were also told that, 'If we have raised anything we were not happy with we have had no problems getting it done'.
People living there were able to join in organised activities if they wanted to and some people went out into the local community. We saw people were able to follow their own faiths and attend religious services if they wanted to. There was a multi denominational religious service on the day we visited. We saw staff asking people if they wanted to attend the service.
Records confirmed people's preferences, interests and different needs had been recorded and care and support had been provided that met their wishes.
Is the service well-led?
At our visit in April 2014 we found that the provider did not have a robust recruitment procedure in practice. At this inspection the provider had made the improvements they stated in their action plan. The records we viewed had all of the information required by regulation. This meant that the provider had improved the systems in operation to help make sure people being employed were fit for the work and had the right qualifications and skills.
The staffing levels in the home had been affected by shortages, staff sickness, suspensions and leave. In response to this the provider had put interim contingency actions in place. This included using agency staff in the short term to maintain better staffing.
Quality assurance processes were in place. We saw that audits, or checks of medicines, were done to assess the way medicines were managed. However, we had concerns about the way medicines were handled and these were not identified or managed appropriately through the audits. Monitoring of equipment cleaning and visual checks had also not been effectively monitored.
On our inspection of 12 November 2013 we made a compliance action requiring them to be compliant with the provisions of the regulation for the safety and suitability of premises. We were given timescales for this work to start. These timescales had not been kept by the provider to protect people from the risks associated with unsuitable and unhygienic environments.
Below is a summary of what we found. The summary is based upon our observations, discussions with people who used the service, their relatives and the staff who supported them and from looking at the records held in the home. We also observed the interactions between people living there and the staff supporting and caring for them.
If you want to see the evidence that supports our summary please read the full report.
Is the service safe?
At a previous inspection we found people were not being protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage them. We found that improvements had been made to medication management. We saw that appropriate arrangements were in place in relation to the management and recording of medicines to help ensure they were given safely.
There were enough staff on duty to meet the needs of the people who lived at the home and we saw they had received training appropriate to their role. The provider had contingency plans in place for dealing with foreseeable emergencies including staffing.
Recruitment records for staff who had recently been employed did not contain all the information required by the Health and Social Care Act 2008. This meant the provider could not demonstrate that the staff recently employed to work at the home were suitable and of good character to support the people living in the home. A compliance action has been set for this and the provider must tell us how they plan to improve.
CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes and we saw that proper policies and procedures were in place.
Is the service effective?
People told us that they were happy with the care they received and felt their needs had been met. People spoke well of the staff caring for them and said that they felt staff listened to what they had to say and did as they asked.
We saw in care plans that people's health and care needs had been assessed with them and/or their families and that this was reviewed regularly. Risks to their health and wellbeing had been assessed and plans put in place to manage them.
Specialist dietary, mobility and equipment needs had been identified in care plans and action had been taken to meet them. We found that the provider had procedures in place for obtaining valid consent and what people’s wishes were if their health deteriorated. However evidence of who held legal authority for a person under power of attorney was not evident in practice within people's care files. This meant that staff did not have prompt access to this information.
People's different needs were taken into account with the layout of the home and the signage used to promote their understanding and independence. A major refurbishment programme was being implemented to improve the environment for the people living there. We saw confirmation of this.
People who live there and relatives we spoke with confirmed there were a range of activities for people to take part in. Relatives told us the staff made them welcome and kept them informed about any changes in their relative’s needs.
Is the service caring?
People we saw in the home were supported by suitably trained and supportive staff. We saw that care workers gave encouragement when supporting people and gave people the time to respond. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.
From our observations and what people told us we found that people's preferences, personal interests and wishes were discussed with them and recorded. We were told staff were "kind” and “reassuring”. One person told us that, “When I arrived they told me I would be alright”. We observed that staff interacted with people in a positive way.
Is the service responsive?
People's needs had been appropriately assessed before they moved into the home. People told us they had key workers and also about the 'service user of the day' that focused upon a different person each day. It also helped to make sure that all care files, and risk assessments were reviewed.
Records confirmed people's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided that met their wishes. We found that the manager monitored complaints and had responded under the home’s procedures.
Is the service well-led?
Quality assurance processes were in place and people told us they were asked for their feedback on the service they received. This was through satisfaction surveys and via regular home meetings.
The staff told us that the management team was supportive and held regular meetings to promote good communication. Staff told us they were supported by the management team and had been given opportunities to train and develop professionally.
The service kept records of all accidents and incidents that had occurred in the home and also of notifications required by regulation to CQC. The service worked well with other key organisations, including the community mental health team, the local authority and safeguarding teams. This approach helped to support care provision and service development.
Whilst people who we spoke with were happy with the care they received we saw that medicines were not always managed properly. In particular we saw records for creams and care plans relating to medication that were inadequate and did not show that appropriate care was provided.
We saw that staff treated people with dignity and respect and support was provided in a warm and friendly manner. We saw that people were able to join in meaningful and sociable activities if they wished.
Staff liaised with other healthcare professionals and organisations to ensure timely and appropriate treatment was provided for people. The provider had effective recruitment procedures in place and had carried out relevant checks on the staff they employed. This helped to make sure that staff were suitable for working with the people living there. Staff levels were subject to review.
We found that the physical environment of the home was safe but repairs had not always been carried out immediately as there was not a regular scheme of renewal and refurbishment in place. The furniture and fittings were worn and there were areas of damage that affected hygeine and did not promote wellbeing.
We found that each person living in the home had a plan of care where their assessed needs and preferences were stated. Some records were not clear, and complete or updated promptly. Nutritional screening was in use to help protect people.
We spent a lot of time observing daily life in the home and at the lunch time meal and saw that there were staff available to help people with their meals and prompt them to eat and drink. Some people in the home had limited verbal communication, therefore we spent time observing people's behaviour and their interactions with staff. We did not observe any negative interactions between staff and people in the home. We also observed staff responding to people who needed help at meal times. People told us the food was "good" and told us that they were always given a choice and asked what they liked and wanted. We saw the food choices on the menu board.
On our walk around the building we saw that people had been able to personalise their rooms with their own pictures and personal items.