Heaton House Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment, the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We identified a breach of the legal regulations related to good governance. Further improvements were required with the audit and governance process and with record keeping. Auditing had not identified all of the issues we noted, and audits required adaptation in order to be wholly accurate and meet the needs of the provider. Information in care plans was not always accurate, and monitoring charts were not always completed contemporaneously. The provider was using an overarching improvement plan on which to document actions required, as well as detail those which had already been completed, to help drive improvements and ensure greater oversight. We received positive feedback from people, relatives and staff about the current home manager and the improvements they had overseen since being in post.

This service scored 57 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Since the last assessment, the deputy manager had been promoted to the position of home manager. During this assessment, positive feedback was provided by people and relatives about the home manager and the positive impact this had on the home, and changes which had been made. Comments included, “‘I know [manager’s name] well. They are trying to put things right” and “‘I feel that this is a much better managed home now. I know the manager; they listen and do what they can.” Staff also spoke positively. One stated when asked if the home was well-led, “Now? Yes, but if you’d asked me 3 months ago, I would have said no. We have a new manager, and it’s made a massive difference. They know their job and what needs to be done.”

During the assessment, the manager told us, they had decided not to recruit a deputy to support them in running the home, but to have 2 team leaders instead. This was a model they had used elsewhere which had worked well. Both team leaders had been recruited and were in the process of being trained to carry out the role.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We found improvements were required with governance processes, record keeping and completion of monitoring charts. The provider had an audit schedule in place, and audits were being completed in line with this. However, the auditing process was not fully robust. The provider was using generic audits provided by an external compliance company. These had not been adapted or edited, to ensure they were specific to Heaton House and the areas which needed to be audited. The home manager told us the compliance company had advised them to mark any sections which were not relevant as compliant. This meant the overall compliance score for some audits was not always an accurate reflection, as things not in place or being done, were being marked as compliant. For example, the environment audit included a section for confirming the laundry had a separate entry and exit door. This section had been marked yes, despite the home only having one door to the laundry, not two. We also noted some audits had compliance scores of 94% or over, despite there being a number of overdue or incomplete actions listed on the audit document. It was noted some of the areas linked to these actions had been marked as compliant on the audit.

We identified issues with contemporaneous record keeping, which included information in care plans, as reported on in the person-centred care quality statement. We also noted gaps in people’s monitoring charts, this included those used to document repositioning, personal hygiene and oral care. As a result, we could not confirm people had received care in line with their assessed needs.

Other processes to assess the service and people’s care were being completed more accurately and consistently. These included ‘resident of the day’ and daily walk rounds. The provider had also introduced a new governance matrix, which was used to monitor compliance in a number of areas to help improve oversight.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider used an overarching action plan to record areas for improvement, updates on progress and confirm completion. We noted SMART goal setting had been used in completion of the action plan. SMART stands for specific, measurable, achievable, realistic and timebound, and is a recognised method of ensuring goals or actions are set in an effective and productive way. The action plan contained 2 sections. One for current and one for completed actions, to ensure a record of all improvements completed over time was preserved. We did note, not all actions from the providers internal audit process had been transferred to the action plan, which would be useful to ensure effective oversight is maintained. This may have accounted for the number of overdue or incomplete actions on the audits we viewed. The home manager told us they had experienced some issues with the functionality of the audit document, which had resulted in actions not being removed or updated as required.