Heathlands Care Centre

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 requires improvement. At this assessment the rating has remained 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. At our last three inspections the provider was in breach of the legal regulations in relation to people’s safe care and treatment and the management oversight of the service. Improvements were not found at this assessment, and the provider remained in breach of these regulations. In addition, the provider was in breach of legal regulation in relation to the safe recruitment of staff. The provider was no longer in breach of regulation relating to safeguarding although further improvement in the structures and processes in this area were needed.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. Staff did not listen to concerns about safety and did not investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

People were not always protected from the risk of harm as accidents and incidents were not comprehensively reviewed to ensure appropriate action was taken. We found a number of incident forms relating to unexplained bruising and people going into other people’s rooms uninvited. These incidents had not been fully investigated, and control measure had not always been put in place to minimise risks to people going forward. On occasions this lack of action had led to increasingly more significant concerns which impacted people’s safety and wellbeing. Whilst staff had reported the majority of incidents, we found some examples of concerns only being reported when family or other professionals identified them.

The manager prepared a monthly report of incidents and accidents although this did not always identify trends and themes. Where these were identified, recommended actions were not always taken. For example, a number of incidents were due to people’s anxiety and distressed behaviour. One recommended action was to access additional staff training to ensure staff were skilled in supporting people in this area. There was no evidence this training had been sourced or booked.

In other areas we found accidents and incidents were responded to. This included additional safety measures being implemented when people experienced falls, to help ensure staff were aware of people’s movements.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety and did not make sure there was continuity of care as guidance from professionals was not consistently followed. This included guidance such as support to manage complex diabetes, on-going physiotherapy to maintain comfort and reduce the risk of pain, and information relating to people’s anxiety.

Records in relation to people’s diabetes care showed staff had failed to accurately record blood glucose levels at the required intervals; despite clear information from healthcare professionals in relation to this. There was limited evidence to demonstrate staff had routinely sought additional support from professionals when blood glucose levels were not within desired levels. We observed a person had directions from healthcare professionals in relation to exercises they should be supported with daily. However, there was no care plan in place in relation to this and no record of the person being supported to complete this. The failure to follow professional guidance presented a risk to people’s safe care and treatment.

In other areas we found health and social care professionals were involved in people’s care and support; such as the Speech and Language Therapy Team, Intensive support team and local authority social care teams.

The provider did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People and their relatives told us they felt the service kept people safe from harm. One person told us, “I do feel safe. [Staff] are kind and look after me”. One relative told us, “I consider that she is fully safe. She would certainly tell me if she wasn’t or if there were any problems”.

Despite these comments we found the provider did not share concerns quickly and appropriately, and we found there was a lack of oversight and understanding regarding the reporting of safeguarding concerns.

Incident records showed a number of safeguarding concerns which had not been reported using the correct channels. There had been a number of altercations between people, in addition to people causing distress to others by going into their rooms uninvited. Incidents forms described occasions where staff said due to people’s distressed behaviour; they needed to hold people which had resulted in the person sustaining bruising. A number of these incidents had been reported to other professionals involved in people’s care. However, the provider had failed to ensure they had been reported to the relevant local authority safeguarding team. This meant there was no comprehensive review of the incidents taking into account the views and rights of all those involved. These concerns had not been identified as safeguarding concerns by the manager or provider who had signed them off to say the correct action had been taken. This demonstrated a lack understanding from the leadership team regarding what constitutes a safeguarding concern. In relation to safeguarding people’s rights under the Mental Capacity Act, the manager confirmed they were in the processes of reviewing all Deprivation of Liberty Safeguards (DoLS) applications to ensure these had all been completed as required.

The provider did not work well with people to understand and manage risks. Staff did not consistently provide care to meet people’s needs that was safe and supportive. Guidance on how to support people with their anxiety was not always available to staff. One person’s records stated they could become distressed when being supported with their personal care. Records showed the person had sustained a skin injury whilst staff had been holding their hands to prevent the person from assaulting staff. There was no information for staff to follow regarding how they should support the person to minimise their anxiety. Another person’s records reflected their anxiety was increased due to their disrupted sleep pattern. This not only impacted on the person and their health, but also on their family and other people living at Heathlands. There was no guidance or plan in place to support the person in trying to establish a more consistent sleeping routine.

Risk assessments in relation to people’s skin integrity were not always followed or effectively monitored. We reviewed records for three people at high risk of developing pressure wounds who required support to reposition at regular intervals. These showed a high number of days when staff had failed to record and evidence they had supported people to reposition. For one person, records stated they had only been supported to reposition on 5 out of 30 days in November 2024, and only one of these days evidenced the person being supported to reposition within the required timeframe. This lack of recording and monitoring meant people were at risk of not receiving the care they needed to help keep their skin healthy, and to support the healing of existing pressure wounds.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks of equipment were carried out and recorded to ensure the environment was safe for people. Fire safety systems were monitored and serviced as required. There were processes in place to report maintenance concerns and these were addressed promptly to minimise any disruption to people. The maintenance manager was an integral part of the team at Heathlands and ensured they took account of people’s needs when completing checks and repairs.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The majority of people we spoke with told us they felt staffing levels needed to increase. One person said, “Staff have too much to do and have too many hats to wear. They need more help. They always seem to be chasing things and they always say they are short too.”

Staff told us they found it difficult to support people safely at times. One staff member said it was not always possible to observe people who were awake and in communal areas at night, as the staff on duty were occupied supporting people in their rooms. They felt this put people at increased risk of falls and increased anxiety. Another staff member told us, “It feels we are rushing a lot of the time.”

The manager told us they regularly reviewed staffing levels in line with people’s needs. However, this did not take into account the views of people, relatives and staff to ensure their concerns were known and addressed.

Systems to ensure staff received a comprehensive induction into their roles were not effective. Staff had induction checklists although no information had been entered after the first week of their employment. In addition, we found the competency of 11 staff members had not been assessed in areas including moving and handling, providing oral health care, providing person centred care and supporting with oral health care. This meant the provider had failed to ensure effective systems were in place to ensure staff were inducted into the service and their competency in providing care assessed.

Staff were not always recruited safely. Staff files contained gaps in employment records, contradictory information between some staff application forms and references, and references not always being taken from the most recent employer. This meant people were at risk of not being supported by suitable staff.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading. Systems were in place to ensure the home was clean and hygienic.

People and their relatives told us living in a clean home where staff were aware of infection risks was important to them. One person told us, “Everything is always lovely and clean. They work hard at that.” Staff told us they had access to personal protective equipment (PPE). One staff member told us, “We use gloves and aprons when we need them. They are all around the home for us to access.” We observed staff both using and disposing of PPE safely. Housekeeping and maintenance staff followed cleaning schedules and regular checks within the home to minimise risks.

The provider did not always make sure that medicines were monitored and administered safely.

People told us they felt they received their medicines safely. When asked about medicines one person told us, “That goes well, the nurse comes in regularly”.

We found the majority of people’s day to day medicines were adequately managed. However, guidance and records in relation to as and when required medicines (PRN), skin patches and topical creams were not always clear which presented risks to people’s safety.

Records in relation to a person living with a long term health condition did not provide information to staff on how the condition impacted the person. This meant staff may not recognise when emergency medicines should be administered. The protocol for administration of emergency medicines was also unclear which meant the person was at risk of not receiving the right dose at the right time.

We reviewed a number of protocols for people who were prescribed PRN medicines for constipation and pain relief. The guidance was not always consistent, and where people were prescribed more than one medicine for the same condition it was not made clear how these should be used.

Records in relation to topical creams demonstrated these were not always applied as directed. Charts for 4 people showed creams prescribed to be used several times a day had not been applied for over 24 hours. Staff also completed charts to monitor the application of skin patches designed to provide slow-release medicines over a set period of time. One person’s records showed their skin patch needed to be changed every 24hour. However, on 4 occasions over an 11-day period, staff reported the patch was not in situ when they went to change it. There was no record of how this was investigated or monitored going forward. This put the person at risk of not receiving their medicines as prescribed and placed others at risk of harm due to the patch not being disposed of safely.