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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment, the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We identified a breach of the legal regulations. Medicines management continued to require improvement, as the provider had not made sure records for people's medicines and treatments were accurate and complete. This meant people were placed at risk of harm. People told us they felt safe and knew how to report concerns. Monitoring of safeguarding referrals had improved, although we noted 2 complaints which included allegations of neglect, had not been reported to the local authority. Staff had logged any accidents and incidents on the provider’s electronic system but had not consistently recorded follow up actions taken. However, the home manager had included this information in their own records. Risks to people were assessed and people were happy with the support provided to keep them safe. Enough staff were deployed to meet people’s needs, with a dependency tool now used to support this process. Staff were recruited safely and completed required training and received regular supervision, to ensure they had the necessary skills and support to carry out their roles. The environment was safe with regular checks completed and certification on place, to confirm equipment had been serviced and was fit for purpose.

This service scored 56 (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.

People told us they felt safe living at the home and relatives also had no concerns about safety. Comments included, “I am happy living here” and “I feel that it's safe” and “I feel that [relative] is safe here.” Staff received training in safeguarding and were able to explain how to report concerns. A new safeguarding log had been introduced, on which any safeguarding referrals to the local authority were recorded. The log now included a section to document if a CQC notification was required and had been sent off, as this had been identified as an issue at our last assessment. However, the log did not currently have an outcome and lessons learned section, to allow the provider to demonstrate how practices had been amended to reduce the chances of a similar issue occurring again. We also noted 2 complaints submitted by people living at the home, included information which suggested neglect may have occurred. As this is a type of abuse, safeguarding alerts should have been raised, but this had not yet been done. Accidents and incidents were logged on the provider’s new electronic care planning system. We found the section where staff should document follow up actions taken, had not been completed consistently. However, the manager had reviewed each incident and recorded this information in their section.

The provider used an electronic care planning system. Peoples electronic care records included a number of generic and individual assessments, which explained risks to people and how these would be managed. People and relatives were happy with how risks and incidents had been managed, this included falls. One person told us, “I have had some falls. I am very clumsy, but the staff always help and get me right.” A relative told us how their family member had experienced a number of falls at home and was no longer safe living on their own. However, since moving into Heaton House, they had not fallen due to the actions taken to keep them safe. Although risks assessments were in place, we were unable to confirm people and/or relatives had been involved in their completion, as there was no obvious section for documenting this on the new care planning system. However, we did note relatives were in the process of being invited into the home, to go through care documentation with the manger. The home’s contingency plan had been updated since our last assessment, and now contained details of transportation arrangements, to ensure people could get to alternate accommodations safely, should Heaton House become uninhabitable in an emergency. Personal emergency evacuation plans were in place for each person, which explained what support they would need to evacuate in an emergency.

Work to improve the safety of the environment was ongoing, though the vast majority of doors and in some cases, door frames had been replaced. The risk assessment relating to building works had been updated since our last assessment and was now more robust. Contractors were now entering and exiting the home via the basement area, which reduced the risk of people being able to leave the home unplanned, through doors left open whilst materials were brought in. Safety checks had been completed with certification in place, to confirm utilities and equipment were safe to use. Regular fire safety checks were being completed. The provider was carrying out audits of the environment and safety checks in place, to ensure these were being done effectively. The provider had ceased the use of a risk register, to log risks and how these would be met. This information was instead added to the home’s improvement plan, to reduce the number of documents in use.

People and relatives commented on the improvements being made to the environment, and how this improved safety. One relative stated, “Better safety measures are now in place. For example, there's a new front door with pin protection and new doors are being fitted to rooms. The environment is more pleasant, clean and I like it.”

Overall, people, relatives and staff told us enough staff were deployed to meet needs and keep people safe. Comments included, “I think there are sufficient staff at the moment” and “Yes there are enough staff on shift staff, they are placed throughout the home where they're needed.” A dependency tool was now being used. This is a formal system which determines how many staff are needed to meet people’s needs. Through using the tool, the provider had identified an additional staff member was required at night, which had been addressed. Some people and relatives commented on how often communal areas were left unsupported. We also noted this during our site visits. We observed staff popping in and out to check on people, but there was no set pattern to this. We did note, and people confirmed, staff responded timely to requests for help.

We found all care staff had completed induction training again, with updated booklets in staff files. This allowed the provider to demonstrate staff had the necessary skills to carry out their roles. A new refresher training schedule was in place and monitored via the governance matrix, this ensured staff remained up to date with their training. A new supervision & appraisal matrix had also been introduced for 2025; meetings were scheduled in line with the providers policy. We noted appraisals had been carried out with majority of staff in either December 2024 or January 2025. However, a review of staff personnel files showed further work was still needed to ensure all staff had completed planned supervisions.

Staff were recruited safely, with all necessary checks and documentation in place.

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.

During the site visit we found medicine errors the provider had not identified. The site of application of topical preparations, such as patches, was not always recorded; this meant the manufacturers guidance to rotate patches might not have been adhered to which placed people at risk of skin irritation. Information to support staff to safely administer ‘when required’ medicines was not always available. When the information was available it was not person centred and did not always contain all required information, for example, if there was an option to give 1 or 2 tablets. When people were given a ‘when required’ medicine, for example an analgesic, the outcome was not always recorded, therefore staff could not monitor the effectiveness of the medicine and escalate to a prescriber if needed. When people had thickener added to their drinks, to reduce the risk of choking, this was not always recorded. As a result, we were not assured the thickener was added to their drinks as needed. Additional information and special instructions, for example to take medicines with or after food, was not always included on the medicines administration record, therefore there was a risk the medicines might not be administered in line with manufacturer’s instructions. The provider completed medicines audits; however, they had not identified the issues found during this assessment, therefore we were not assured the audits had been effective in identifying and driving improvements. One person we spoke with told us they got their medicines when they need them and as prescribed. Medicines were stored securely. Staff worked with other healthcare professionals to improve the management of medicines at the home.