Heritage Care Place

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 this assessment we rated this key question 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 found 1 breach of regulation in respect of safe care and treatment. Risk assessments were not always in place for people and there was a risk staff did not always provide care safely.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A system was in place to report, record and monitor incidents and accidents to help support people safely. We looked at a sample of the most recent incidents/accident recorded. These detailed the nature of the incident/accident, immediate actions taken, the outcome and any follow up actions taken. However, there was a lack of information about lessons to be learnt following an incident/accident. We raised this with the registered manager who advised that the form would be amended to include this.

Incidents and accidents were discussed in meetings so that staff had an opportunity to share information and learn from one another.

People told us they were able to openly speak with staff and management. They were aware of the complaints process.

People told us they were informed and involved in their care and support planning.

Staff spoke confidently about the processes to report concerns and raise issues about people’s safety. They were also confident, their concerns would be listened to and acted upon by management.

People told us they were safe in the presence of care staff. When asked if they felt safe, a person said, “Yes I do feel safe around care staff.” Another person said, “I do feel safe with the carers.” However, another person said, “Yes and no. I feel safe with most of the carers but not all of them.”

Safeguarding procedures were in place. These provided guidance about the action to take if staff had concerns about the welfare of people. Training records showed staff had completed safeguarding training.

Staff told us they felt confident reporting concerns to management and wouldn’t hesitate to do so. However, not all staff were aware that they could also report their concerns to the local authority safeguarding team if they felt they needed to . We discussed this with the registered manager who advised that staff would receive further refresher training.

Potential risks to people's safety were not always assessed appropriately and risk robust management plans were not always in place to manage identified risks. This meant people were at risk of receiving unsafe care and treatment .

People's care records included some risk assessments. Some risk assessment contained limited information about how to mitigate risks and some areas of risk were not identified. For example, a person had a moving and handling risk assessment, but this failed to detail that they were at risk of falls. We also found that there were instances where there was not a risk assessment in place for specific health issues. For example, a person had epilepsy, but there was no risk assessment detailing signs to look out for and what action to take in the event of a seizure. Another person had a medical condition that affects blood flow to their limbs and there was not an appropriate risk assessment in place to guide staff. We noted that a person’s care plan stated that they had ‘mobility issues’ but there was no risk assessment in place detailing how to support this person manage risks associated with this.

The lack of risk assessments in place meant that staff had not been provided with suitable guidance to minimise the risk of people receiving unsafe care and lacked guidance on what to do in response to symptoms of these conditions.

We discussed this with registered manager who told us they would take immediate action to address this issue. Following the site visit, they sent us amended versions of risk assessments which included details of risks and guidance on how to reduce risks. However, we need evidence that this has consistently been implemented and will follow this up at the next inspection.

The provider had carried out an assessment of people’s homes to help identify potential risks. They made sure equipment, facilities and technology supported the delivery of safe care.

Some people told us that care staff were not always punctual and did not always stay for the full duration of their visit. They also said they didn’t always know which care staff were visiting to provide their care.



The agency had an electronic homecare monitoring system in place to monitor care staff’s timekeeping and punctuality in real time. The system would flag up if care staff had not logged a call to indicate they had arrived at the person's home and were running late.

We looked at a sample of staff login and log out records and found that care staff were mostly on time. However, there were occasions where care staff were significantly late for visits. We raised this with the registered manager who advised that they were aware of this issue and were reviewing this with care staff looking at ways to support staff to address this.

Policies and procedures were in place to help recruit staff safely. Checks on the suitability of potential staff were completed. This included obtaining references and checks with the Disclosure and Barring Service (DBS). The DBS helps employers make safer recruitment decisions and help prevent unsuitable people from working in care services.

People told us that staff followed good infection control processes, including washing their hands, keeping people’s home’s clean and wearing personal protective equipment (PPE). A person said, “[Care staff] are scrupulous with their hygiene.”

Infection prevention and control policies were in place. Staff had completed infection prevention and control training and understood infection, prevention, and control procedures.

Care plans recorded the type of support people required with their medicines and listed people's prescribed medicines. The registered manager advised that they supported 1 person with medicines. We looked at a sample of Medicines Administration Records (MARs) for this person and found that these were completed fully with no unexplained gaps.

Another person’s care plan stated that they wanted to be ‘prompted’ with their medicines. However, there were no MARs in place for this person. Therefore, there were no records to show this person had received their medicines as prescribed. We raised this with the registered manager who confirmed that staff did prompt this person and they would immediately implement a MAR for this person and ensure that any form of medicines support was recorded on a MAR.



Staff had their competency to administer people’s medicines safely assessed to help ensure they had the skills and knowledge to do so.