Heathside Retirement Home

Updated 29 July 2021

The inspection

This was a targeted inspection to check whether actions had been taken to address the breach identified at the last inspection in relation to Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Heathside is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had two managers registered with the Care Quality Commission, one of whom was also the provider’s senior partner. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. For the purpose of this report, we will refer to the managers as the senior partner and registered manager. The senior partner was present during our inspection and we spoke with the registered manager by telephone after the inspection.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because we wanted to be sure the senior partner or registered manager would be available to speak with us.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection.

During the inspection

We spoke with two people who used the service about their experience of the care provided. We spoke with seven members of staff including the senior partner, training and development manager, assistant managers, and care workers. We observed interactions between people and members of staff during the inspection.

We reviewed a range of records. This included two people’s care records and multiple medication records. A variety of records relating to the management of the service, including quality audits, were reviewed

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at improvement plans and a clinical commissioning group (CCG) medicines review for the home. We spoke with three relatives of people living at Heathside to gather their feedback about the home.

Updated 29 July 2021

About the service

Heathside Retirement Home is a residential care home providing personal care to 30 people aged 65 and over at the time of the inspection. The service can support up to 30 people.

People’s experience of using this service and what we found

At this inspection we only looked at the key questions safe and well led.

The quality assurance system was not robust. The registered manager was not pro-active in communicating with senior staff members about the audits they had completed.

Staff had not always received the necessary support and training to be able to effectively write risk assessments and care plans. One person's care plan had not been reviewed in a timely manner after they had moved to the service, resulting in the care plan not being reflective of their needs.

Accidents and incidents were recorded and reviewed by the registered manager. However, the staff had not recognised the seriousness of one incident, which meant it was not correctly recorded. The registered manager, partner and training and development manager said they were not aware of a change in one person’s support needs, which meant risks for this person had not been adequately assessed and managed.

People received their medicines as prescribed. We have made a recommendation about reviewing how the medicines round is managed.

Staff felt able to speak to the registered manager and regular staff meetings and supervision meetings were held.

People and relatives said they felt safe living at Heathside.

There were sufficient staff on duty to meet people’s identified needs. Infection prevention and control measures had been reviewed in light of the Covid-19 pandemic.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published August 2018).

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about the risk management and quality assurance systems in place at the service. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with the governance and quality assurance at the service, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Heathside Retirement Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a breach in relation to the quality assurance and oversight of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan and will meet with the provider to discuss what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.