Heaton House Care Home

Following the last assessment, we took regulatory action due to identifying breaches of legal regulation relating to governance and record keeping. Improvements were not found at this assessment, and the provider remained in breach of these regulations. The provider was also previously in breach of 2 further legal regulations relating to the management of medicines, staff recruitment, training and support. Improvements were found at this assessment, and the provider was no longer in breach of these regulations.

Heaton House Care Home is a residential care home, registered to support up to 24 older people, including those living with dementia. The assessment included 3 on site visits, with additional information and evidence reviewed remotely. At the time of the inspection, 23 people were being supported.

There was a registered manager at the home. 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. However, the day-to-day running of the service was overseen by a home manager who had been in post approximately 2 years and had submitted an application to register with CQC; we are currently assessing this application.

Since the previous inspection the provider had taken action to address some of the concerns identified and improvements were evident in several areas of the service. However, we identified ongoing weaknesses in oversight systems, which had not consistently identified or addressed inaccuracies, omissions and inconsistencies within care records.

People’s records were not always accurate, complete or contemporaneous, and in some cases contained omissions, inconsistencies or contradictory information. These issues reduced our ability to be assured people were receiving safe care and treatment. Although audits and monitoring processes were in place, they had not been sufficiently effective in identifying all areas of concern or driving sustained improvement.

Care records and monitoring charts had not always been completed fully or in enough detail. The provider needed to further review and strengthen governance and oversight arrangements to ensure quality assurance processes were effective in identifying, escalating and addressing concerns. Audit findings, incidents, complaints and feedback was not used effectively to drive continuous improvement and prevent recurrence of identified issues.

We found concerns regarding the building and outside environment, and we asked the provider to review all windows within the home to ensure they met Health and Safety Executive (HSE) guidelines about window restrictors. We asked the provider to remove old and discarded items left in the garden and outside areas which presented an unpleasant outlook for people and a risk to people and any visitors; arrangements were made to remove these during the inspection.

Staff protected and respected people’s privacy and dignity and responded to their individual needs, however, we observed some people waiting for long periods for staff support. People told us they felt safe living at the home. Concerns and complaints were managed appropriately, however, there was limited information on how the registered manager analysed trends and shared learning across the team to improve service delivery.

We have asked the provider for an action plan in response to the concerns found at this assessment.