Heartly Green

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 good. At this assessment the rating has changed to 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.

The service was in breach of legal regulation in relation to safe care and treatment for medicines and staffing.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Learning and oversight were not consistently effective in identifying and addressing issues prior to this inspection. This was particularly evident in relation to medicines management. This meant the provider could not always demonstrate learning from errors and near misses was embedded into practice in a way which prevented recurrence and provided consistent assurance to people.

We saw examples of leaders responding appropriately to the issues we identified during the inspection, and some immediate action was taken to address concerns. For example, issues relating to communication with catering staff were remedied quickly and the manager assured us oversight arrangements would be strengthened going forward.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Staff demonstrated good knowledge of people’s day-to-day needs, and we saw evidence of systems which supported continuity of care; however, these systems did not always reflect people’s current care needs. We identified some visits from health professionals and advice regarding care had either not been input into care planning systems or had been delayed. Leaders provided paperwork promptly and applied updates which gave some assurances in this area.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Whilst staff tried to ensure people were protected from abuse, discrimination, avoidable harm and neglect, the staffing levels at the home meant this was not always possible. Feedback from partners indicated that the registered manager was engaging with the local authority to address and learn from safeguarding investigations.

Some people living at the service had a Deprivation of Liberty Safeguard in place. This meant the decision for where they lived and some restrictions on their daily lives had been approved by authorities, because the person was unable to make these decisions themselves. The provider was meeting conditions attached to the sample of authorisations we reviewed. Staff had received safeguarding training and could describe safeguarding processes including how they would respond if a concern was raised.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments did not always accurately reflect changes in need; updates to these needed to be timelier. Staff did not always have clear guidance on how to support people safely. The provider had an action plan and was in the process of reviewing all risk assessments and care plans to ensure information was personalised, accurate and that staff had clear guidance to support people safely.

Kitchen staff demonstrated a good understanding of people who needed modified diets, due to choking risks or identified health conditions such as diabetes. However, kitchen staff relied on this information being verbally communicated by staff, either on admission or following any new guidance from the speech and language team (SaLT). We were not assured this process was robust enough to ensure people remained safe and brought this to the manager’s attention. Action was taken to strengthen this process; copies of any guidelines in relation to modified food and drinks were given to catering staff.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Records showed moving and handling equipment was serviced and maintained as required and communal areas at the front of the home were nicely decorated and well-presented having recently undergone refurbishment. However, we identified some environmental issues which required attention. The internal courtyard, accessible from each ground floor unit, was overgrown with weeds and contained old garden furniture. People who were independently mobile were able to access the garden, but we were not assured they would always be safe because of the potential hazards in the area. A relative commented, “The whole point of [person’s name] coming here was so that he could walk outside; he loves to be outside, but it’s dangerous for him.”

We identified some bedrooms that required updating. There had been a delay in addressing home improvements due to the absence of a maintenance person; a new employee commenced in the role on the third day of inspection.

These issues did not present an immediate risk to people but required timely action to ensure the environment remained fully safe and well maintained. Soon after the inspection the manager informed us a contractor had been appointed to maintain the garden area and this environment had been improved.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Staffing levels did not always promote safe care that met people’s individual needs.

During peak periods of support, such as mornings, mealtimes and bedtimes, staffing levels on each of the 4 units were minimal and staff were extremely busy. It was apparent from observations and discussions with people and relatives that there were insufficient numbers of staff at times to appropriately manage people’s needs and respond in a timely and person-centred manner. One relative commented, “It’s good here and the carers are wonderful but there is definitely not enough staff sometimes.” Another relative said, “There is not enough care staff and at night there is even less, so residents are left unattended.” On our second day of inspection we observed 9 people in a lounge without oversight from staff for over 10 minutes, as staff were busy supporting others with their morning care routines.

Team leaders were shared between 2 units, one on the ground floor and one on the top floor. An incident occurred on 1 unit on the first day of inspection and there were delays in notifying a team leader to help deal with this. On this occasion management were still on site to help. We observed care and support was also delayed on occasions due to the unavailability of staff to provide the right levels of care. This was further supported by speaking with staff. There were no supernumerary hours allocated to team leaders which affected the completion of electronic care plans in a timely manner.

Staff were recruited safely, and mandatory checks were completed prior to staff commencing employment. Training compliance was good, and staff were able to describe the training they had completed and how this assisted them in their role. Staff were keen to develop their skills and knowledge further. There was minimal use of agency staff as the manager had access to a pool of bank staff.

The provider did not always assess or manage the risk of infection.

External audits completed in 2025 had identified multiple and significant concerns with infection control management. At the time of our inspection, the service had addressed most of the concerns identified by these audits but was looking to further strengthen practices and processes.

We spoke with a professional involved with infection control audits. Whilst they acknowledged the home had improved since poor audits in 2025, practices and assurance were still not fully consistent. There was evidence within care plans that people were provided with hand hygiene, however this was not always at meal times. During our lunch time observations on all 4 units we saw good hand hygiene was not checked or promoted prior to people receiving and eating meals, nor were hand wipes routinely made available for people. We were not yet assured infection risks were always being managed well.

Staff had access to personal protective equipment (PPE) and this was stored appropriately. Cleaning products were available and stored securely. Staff told us they understood how to manage infection outbreaks and outlined action they would take in the event of an outbreak.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were not always administered in line with prescribing instructions or manufacturers’ guidance.

Medicines to be given before food, were given at the same as medicines to be given after food; this meant the medicines might not work properly. Medicines that were prescribed at specified times were not always given on time; this meant people might experience symptoms the medicine was prescribed to treat. In addition, when medicines required a specific time interval between doses, we found this was not always observed; this meant people might experience unwanted side effects.

Medicine administration records and medicine related documentation were not always accurate, including people’s allergy information and information around their prescribed medicines. This placed people at risk of harm. When people were prescribed topical medication preparations, such as patches, records were not always maintained to show they were applied in line with the manufacturer’s directions, which placed people at risk of skin irritation.

Risks associated with high-risk medicines, such as anticoagulants, topical preparations and flammable emollients were not always adequately assessed or clearly documented to guide staff. Information to support staff to administer medicines prescribed to be given ‘when required’ were not always in place or sufficiently person-centred; this meant there was a risk people might not get their medicines when they needed them.