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Reports


Inspection carried out on 17 April 2018

During a routine inspection

The inspection took place on the 17 and 20 April 2018 and was unannounced. This meant that the provider and staff did not know we would be visiting.

Heatherfield Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home can accommodate up to 74 people. The home is divided into three areas for those who have general nursing, dementia care and younger physically disabled care needs [YPD]. The provider referred to these areas as units so we have used this terminology throughout the report. There were 60 people living at the service at the time of the inspection.

At our last inspection in November 2017, we found four breaches of the Health and Social Care Act 2008. These related to safe care and treatment, staffing, receiving and acting upon complaints and good governance. We placed conditions on the provider's registration to minimise the risk of people being exposed to harm. We rated the service as requires improvement overall and inadequate in the well-led key question.

At this inspection we found that improvements had been made and they were now meeting all the regulations we inspected. Following the inspection, we agreed that the conditions placed upon the provider's registration could be removed.

A new manager was in post. They had commenced employment in January 2018 and become registered with the Care Quality Commission [CQC] in April 2018. A registered manager is a person who has registered with the 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.

There were safeguarding procedures in place. Staff did not raise any concerns about staff practices at the service. Safeguarding incidents were appropriately referred to the local authority and other relevant bodies.

There were sufficient staff deployed although we recommended that the provider reviews staff deployment on the young physically disabled unit because of the mixed feedback we received from people, relatives and staff from this unit. Agency staff were still used at the service. The provider tried to ensure the same agency staff were requested for consistency. Safe recruitment procedures were followed and staff had completed training in safe working practices and to meet the specific needs of people. An effective induction process was now in place which was linked to the Care Certificate. There was a supervision and appraisal system in place to help ensure staff were supported in their roles.

We checked the management of medicines. We identified several minor medicines recording issues in the nursing unit. These were addressed by our second visit to the service. Enteral feeding and medicines administration was now carried out safely. Enteral feeding refers to the delivery of a nutritionally complete feed via a tube, directly into the stomach or bowel.

Action was being taken to ensure the environment met the needs of the needs of people who used the service. New flooring was being laid and areas of interest had been added in the dementia care unit.

The maintenance of care records and charts had improved and were more detailed. They now reflected people’s needs. We identified minor shortfalls regarding enteral records which the registered manager told us would be addressed.

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 place supported this practice.

People were supported with their dietary requirements. Staff were attentive to people’s needs and provided discreet support. Portion sizes were reflective of people’s preferences and requirements. Meals appeared appetising and were served at the correct temperature.

We observed positive interactions between people and staff. Staff spoke with people respectfully and provided discreet support.

There were four activities coordinators employed, although one activities coordinator was on leave. There was an activities programme in place.

Most people, relatives and staff told us that improvements had been made. Less positive feedback was received from some people, a relative and several staff on the YPD unit. This related to staff deployment, activities and meals. Due to the mixed feedback we received, we recommended that the provider reviews the culture, involvement and person-centred approach on the YPD unit.

A complaints procedure was in place. Complaints were documented and action taken. Feedback systems were in place to obtain people and their representatives' views.

The management structure had been strengthened. The registered manager was supported by a deputy manager. New team leader posts had been introduced on each of the units to oversee the care and support provided. The head of compliance and a compliance officer oversaw the operational management of the service. Strategic oversight was provided by the head of care and the director who were both actively involved in the service and visited regularly.

New monitoring and communication systems had been introduced. These were in the process of being embedded into practice.

The service has a history of non-compliance with the regulations. Improvements which had been made at previous inspections were not always maintained. In addition, there had been a number of different managers at the service since 2013. Action was therefore required to ensure that the improvements made at this inspection were maintained and sustained.

Inspection carried out on 3 November 2017

During a routine inspection

We last inspected Heatherfield Care Home in December 2016 where we identified two breaches of the regulations relating to safe care and treatment and good governance. We rated the service ‘requires improvement.’

Following our inspection, the provider sent us an action plan which stated what action they were going to take to improve.

Heatherfield Care Home provides accommodation and care for up to 74 people. The home is divided into three units for those who have general nursing, dementia care and younger physically disabled needs. Accommodation is spread over two floors. There were 68 people living at the home at the time of the inspection.

A manager was in post. She had commenced employment in May 2017 and applied to register with the Care Quality Commission as a 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.

Prior to the inspection, we received information of concern regarding staffing levels, the maintenance of records and certain aspects of people’s care. We brought forward our planned inspection in order to check the concerns raised.

There were continued shortfalls and omissions with regards to the management of medicines. We identified concerns with the care and treatment of people who required enteral feeding. Enteral feeding refers to the delivery of a nutritionally complete feed via a tube, directly into the stomach or bowel.

A high number of agency staff were used. At the time of the inspection, we found there were insufficient suitably qualified, competent, skilled and experienced staff employed.

Staff were knowledgeable about safeguarding and told us they would report any concerns. There were three ongoing safeguarding investigations. Two of these were being investigated by the police. We will monitor the outcome of these safeguarding investigations and action taken by the provider.

The local authority had placed the service into organisational safeguarding. This meant that the local authority was monitoring the whole home.

There was a lack of evidence to demonstrate that safeguarding incidents were monitored and lessons to be learned considered to help identify any changes in practice to ensure continuous improvement.

The training matrix had gaps against certain training courses. Some people, relatives and staff raised concerns about the communication and skills of agency workers. Records of the clinical skills and competencies were not available for most of the agency nurses. There was no evidence of clinical supervision.

We checked the design and décor of the service. There were extensive accessible gardens which had won a number of awards. The service had its own hydrotherapy pool. There was an additional charge if people wished to use this facility. The service also had a cinema room, hairdressing salon and kitchen areas where people could make hot drinks and prepare snacks. However, we found that not all aspects of the environment met best practice guidance relating to supportive environments for people living with dementia. We recommended that the design and decoration of the premises is based on current best practice in relation to the specialist needs of people living at the service.

Some people’s care records had omissions. This meant it was not clear whether care and treatment had been provided.

A complaints procedure was in place. We found however, that not all complaints were recorded or dealt with in line with the provider’s complaints procedure.

An activities programme was in place. Some people and relatives told us that more activities would be appreciated. We recommended that access to and the variety of activities available is kept under review in light of the feedback we received.

We observed positive interactions between staff and people. Staff spoke with people respectfully and provided discreet support.

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 found shortfalls in many areas of the service including the management of medicines, training, the care and treatment for those who required enteral feeding and dealing with complaints. In addition, records relating to people, staff and the management of the service were not always accurate, complete or securely maintained.

Since 2013, we found the provider was breaching one or more regulations at five of our six inspections. This meant that systems were not fully in place to ensure compliance with the regulations and good outcomes for people.

Following our inspection, the head of compliance sent us an action plan and further information detailing the actions they had taken/planned to take to address the shortfalls we identified.

We found four breaches of the Health and Social Care Act 2008. These related to safe care and treatment, staffing, receiving and acting on complaints and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Inspection carried out on 13 December 2016

During a routine inspection

This inspection took place on 13 and 14 December 2016. The visit on the 13 December 2016 was unannounced. This meant that the provider and staff did not know we would be visiting. Heatherfield Care Home provides accommodation and care for up to 74 people. The home is divided into three units for those who have general nursing, dementia nursing and younger physically disabled care needs. Accommodation is spread over two floors. There were 71 people living at the home at the time of the inspection.

The last comprehensive inspection of this service was carried out in February 2015. At that time the service was in breach of Regulation 12 HSCA (RA) Regulations 2014 Safe Care and Treatment. We followed up on this breach at a focussed inspection in August 2015 and saw the breach had been met, however that inspection found the service in breach of Regulation 17 HSCA (RA) Regulations 2014 Good Governance.

During this inspection we found that whilst some actions had been taken to improve the quality and monitoring systems, shortfalls in care remained. The provider’s system had not identified the shortfalls which we found during our inspection.

A registered manager was 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.

Risks related to the receipt of care had not been mitigated. Two people at risk of developing pressure damage were using pressure relieving mattresses which were set incorrectly for their body weight. Nursing staff were unable to tell us when the settings were last checked as there was no formal process for monitoring this equipment.

Risks related to covert medicines had not been assessed. Records were not kept to note where medicines administered via a patch on people's skin had been applied, putting people at risk of discomfort.

People and relatives told us they thought one area of the home was understaffed. The registered manager advised staffing was determined by an assessment of people's needs. We saw from rotas that staffing numbers in the home had met the assessed number. During our inspection the atmosphere was unhurried and people were responded to quickly.

Robust recruitment procedures had been followed to ensure checks the suitability of potential employees had properly considered.

Steps had been taken to mitigate the risk of infection.

During observations in the dementia care unit over lunchtime, we found there were not enough staff to support the people with the highest level of need so they had to wait a considerable amount of time before staff could support them to eat. There was not enough room in the dining room to accommodate people comfortably.

People in the dementia care unit were not offered a choice of meal, and steps had not been taken to ensure that choices could be provided in a way which would meet people's needs.

Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA), and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’.

Where decisions had been made on people’s behalf, records showed capacity had been assessed and best interests process followed. The provider had sought authorisation to deprive people of their liberty where it was considered they would not be able to keep themselves safe if they left the home alone.

The provider had identified a set of training modules for all staff to undertake. We saw this training was monitored to ensure staff stayed up to date with any refresher training required. We have made a recommendation about staff training on the complex needs of some people using the service.

New staff inductions included policies and procedures, shadowing experienced staff and undertaking training. Staff received regular supervisions sessions, an annual appraisal and opportunities to develop their skills and knowledge.

The home was purpose built, and had been designed to meet the needs of the people who used it. Steps had been taken to aid people's orientation on the dementia care unit, but the manager advised us further improvements were planned in this unit to ensure it met best practice for people with dementia conditions.

People and relatives told us the staff were warm and friendly. We observed staff were considerate of people’s privacy and dignity.

Processes were in place to ensure that people were supported in compassionate way, by appropriately trained staff, at the end of their lives.

Assessments of people’s needs and the care plans which described how they should be cared for did not always contain accurate information and some were out of date, which put people at risk of receiving inappropriate care.

The home employed four activities coordinators but some people and relatives told us that there was not enough for people to do.

The provider did not have a robust system to monitor the quality of the service provided. Whilst a scheduled of audits were carried out regularly they had not addressed the shortfalls which our inspection highlighted.

We found two breaches of the Health and Social Care Act 2008. These related to safe care and treatment and good governance.

The provider had not sent us notifications which are a legal requirement of their registration. This was a repeated breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

We will continue to work with the provider to monitor and improve service. You can see further action we have asked the provider to take at the back of the full version of this report.

Inspection carried out on 7 and 13 August 2015

During an inspection to make sure that the improvements required had been made

We carried out an unannounced comprehensive inspection of this service on 2 February 2015. A breach of legal requirements was found in relations to medicines management. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) regulations 2010 - management of medicines.

We undertook this focused inspection on 7 and 13 August 2015 to check that they had followed their plan and to confirm that they now met legal requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Heatherfield Care Home on our website at www.cqc.org.uk

Heatherfield Care Home provides accommodation and care for up to 74 people. The home is divided into three units for those who have general nursing, dementia nursing and younger physically disabled care needs. Accommodation is spread over two floors. There were 73 people living at the home at the time of the inspection.

We checked medicines management and found improvements had been made. We noted however, that some of the medicines systems which had been introduced had not been fully implemented. One person’s allergies had not been documented on her medicines administration record. In addition, protocols for the use of ‘as required’ medicines such as sedatives were not fully in place. The manager told us that this would be addressed immediately.

We spent time looking around the home and saw it was clean and well maintained. We found that one person was able to override the restrictor on his window. This risk had not been assessed. The manager told us that this would be addressed.

Some people and staff informed us that more staff would be beneficial. We observed that staff carried out their duties in a calm unhurried manner. Records were not fully available to evidence that safe recruitment procedures were followed. Following our inspection, the manager informed us that recruitment records were now stored in her office.

We did not plan to look at the well-led domain which relates to the management and governance of the service. However, we found concerns which led us to look at aspects of this domain.

The manager had been in post since December 2014 and was not yet registered with CQC. We had rejected her applications to register with CQC in May and August 2015, because they had been incorrectly completed. We have written to the provider to ascertain what actions they are going to take to ensure that an appropriately completed application is submitted to make sure that the manager is registered with CQC in line with legal requirements.

We found that the provider had not notified us of certain events at the service. These included safeguarding concerns, one death and an incident involving the police. In addition, the manager had not notified us of the outcome of Deprivation of Liberty Safeguards applications in a timely manner. She said that she was in the process of completing these notifications.

Following our inspection, the provider promptly submitted retrospective notifications regarding these incidents and events.

We examined falls analysis records which were completed monthly. We found that the number of falls which were documented on the monthly analysis logs did not always tally with the actual number of falls which had occurred at the service. This meant there was no accurate overview of falls in place.

The provider was not able to provide evidence that other incidents, such as certain safeguarding concerns, were monitored and analysed. We were not made aware of these notifiable incidents until staff informed us and we read people’s care plans. There was no overview of the number of incidents which had occurred and what actions had been taken. This meant patterns or themes of events involving people who lived at the service could not be readily identified and acted upon.

Following our inspection, the provider submitted a notification to amend their name on our system from Heatherfields to Heatherfield Care Home.

We found one breach of the Care Quality Commission Registration Regulations 2009. This related to the failure to notify us of other events and incidents which had occurred at the service which the provider is legally required to inform us of. This is being followed up and we will report on any action when it is complete.

We also found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to good governance. The action we have asked the provider to take can be found at the back of this report.

Inspection carried out on 4 and 5 February 2015

During a routine inspection

The inspection took place on 4 and 5 February 2015. This was an unannounced inspection. We last inspected Heatherfields on 21 February 2014. At that inspection we found the home was meeting all the regulations that we inspected.

Heatherfields is divided into three units and provides accommodation and care for up to 74 people who have general nursing needs, those who live with dementia and younger people who have a physical disability. At the time of our inspection there were 71 people living at the service with two people expected to be moving in very soon.

The service had a manager and they were new to the post in December 2014. They were currently in the process of registering with the Care Quality Commission. 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 found the management of medicines required improvement. For example, as required medicines protocols were not in place, the allergy status of people was not always completed and people had not always received their medicines as prescribed.

People we spoke with told us they felt safe living at the home. Family members also confirmed that they felt their relative was safe. One person said, “Yes, I feel safe. It is alright.”

Staff we spoke with had an understanding of safeguarding and the provider’s whistle blowing procedure. They also knew how to report any concerns they had. The provider had a system in place to log and investigate safeguarding concerns.

Staff undertook risk assessments where required and people were routinely assessed against a range of potential risks, such as falls, mobility and skin damage. We also saw that the service had emergency procedures in place to protect people who lived there, including fire drills. We found that accidents and incidents were reported and dealt with appropriately.

People who used the service, family members and staff all told us they felt there were enough staff to meet people’s needs. The new manager and the quality assurance manager monitored staffing levels to ensure that was enough suitable staff available to meet people’s needs. There were recruitment and selection systems in place to ensure that new staff were fit to care for and support vulnerable adults.

Staff were well supported to carry out their caring role and were skilled and trained to perform their caring responsibilities.

People and family members were happy with the food provided. One person told us, “Nice, I need a decent meal.” And, “I can choose what I like, it is enough.” The provider had systems in place to identify and support people at risk of poor nutrition, including additional support at meal times.

People told us they had access to healthcare professionals. We spoke with a visiting GP who was complimentary about the service and its staff.

Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS). Staff followed the requirements of the Mental Capacity Act 2005 (MCA) and DoLS. MCA assessments and ‘best interests’ decisions had been made where there were doubts about a person’s capacity to make decisions. Applications to the local authority had been made where a DoLS was required. People confirmed that they were asked for permission before receiving any care. One person told us, “[Names of staff] always ask me if they can help me get ready before they do anything.

The provider had made adaptions to various parts of the building, including a cinema and a new café area. They were also about to start refurbishment of the unit for people living with dementia.

People and their family members told us they were well cared for and were treated with dignity and respect. One person told us, “The staff are caring all the time. If I was bored I could ring my bell and the staff would come.” A relative told us, “Staff are great, no problems.”

We made observations over lunchtime and found that staff interaction with people was warm, kind and caring. One staff member was seen singing with one person. Relatives told us they knew staff and staff knew them and they were kept up to date with information regarding their relatives care.

Various activities were planned for people and improvement had been made to increase activity coordinators and to provide a fuller programme of opportunities for people.

People had their needs assessed and the assessments had been used to develop care plans which were tailored around individuals. People were able to choose what they wanted to do and that included when they got up and when they went to bed. One person told us, “The staff are not dictators and don’t tell me what to do and when, they are nice.”

The home’s complaints procedure was available and on display around the service. Where people or relatives had made a complaint, it had been dealt with effectively.

Staff told us the service had a culture of being open and honest. Relatives told us that the manager and staff were approachable and responsive.

People had the opportunity to give their views about the service. There was regular consultation with people and family members and their views were used to improve the service. A ‘service user’ guide had been published and this was provided to people when they moved into the service.

The provider undertook a range of audits to check on the quality of care provided. Information was analysed to look for trends and patterns and to identify learning to improve the quality of the care provided.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 12 (g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to management of medicines. You can see what action we told the provider to take at the back of the full version of this report.

Inspection carried out on 21 February 2014

During an inspection to make sure that the improvements required had been made

We spoke with 10 people, seven relatives and 10 care workers about the care and support provided by the service. One person told us, “I enjoy it here and I think the staff are good and all the girls are really canny. It took me a while to settle in, but I’m happy now.” One relative commented, “We love the place; it’s a really smashing place and they look after her very well.” Another relative said, “The staff all seem to understand my mam very well and she gets good care and support.”

We were unable to speak to all of the people who used the service because of the nature of their condition. We spoke with staff and observed their practices to determine how care and support was delivered.

Relationships between people and staff were clearly good. Relatives told us and we saw in practice staff treated people with respect and helped them to remain as independent as possible.

We found people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plans. Relatives we spoke to were positive about the care and support people received. One relative said, “They understand all my mam's needs. Her care and support is very good and she is well looked after.” Another relative told us, “She gets good care here, without a doubt. She’s happy, she is well looked after, the care is spot on and that’s good enough for me.”

We found that there were suitable numbers of skilled, trained and experienced staff. One relative commented, “The staff all seem confident and competent in what they are doing.” Another relative told us, "They were having staffing problems, but recently there has been a definite improvement and I've seen an increase in staff."

The service had a complaints procedure that detailed the process to be followed in the event of a complaint. This indicated complaints should be documented, investigated and responded to within a set timescale. People and relatives told us that they felt able to raise any concerns or comments about the service.

Inspection carried out on 8, 11 October 2013

During an inspection in response to concerns

We carried out this inspection after we received information of concern about staffing levels and care provided at the service.

We spoke with seven people and 16 relatives to find out their opinions of the care and treatment at the service. One person told us, “The care and support is good when I can get it.” One relative said, “I’m glad she’s here, she’s well looked after.” Another relative told us, “The lack of staff impacts on people’s care and treatment. They can't tend to their needs properly.” One person told us, "There's always a high turnover of staff."

We were unable to speak to all of the people who used the service because of the nature of their condition. We spoke with staff and observed their practices to determine how care and support was delivered.

We found that people’s care, support and treatment were not always properly assessed and their care was not always planned and delivered in a way which met people’s individual needs.

People, relatives and staff told us and we found that suitable numbers of skilled and qualified staff were not always on duty. We spoke with seven people, 16 relatives and 10 members of staff. Six people, 14 relatives and nine members of staff told us they felt that more staff on duty would be appreciated.

The service did not have an effective complaints recording system available. Complaints people made were not always documented or responded to appropriately, in line with the providers own complaints policy.