The Care Quality Commission
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Heaton House Care Home

Overall: Requires improvement read more about inspection ratings

9 Greenmount Lane, Bolton, Lancashire, BL1 5JF (01204) 841988

Provided and run by:
Sevaline Care Homes Limited

Important: The provider of this service changed. See old profile

All Inspections

During an assessment under our new approach

Date of assessment: 28 July to 3 August 2026. The assessment was completed to check if improvements had been made following our last assessment in December 2025.

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.

During an assessment under our new approach

Date of assessment: 2 to 17 December 2025. Heaton House Care Home is a residential care home, registered to support up to 21 older people, including those living with dementia. The assessment included 3 on site visits, with additional information and evidence reviewed remotely.

The assessment was completed to check if improvements had been made following our last assessment in January 2025. Following that assessment, we took regulatory action due to identifying breaches of legal regulation relating to governance and record keeping.

At this assessment, the provider remained in breach of legal regulations relating to governance and record keeping. The provider was also in breach of 2 further legal regulations relating to the management of medicines, staff recruitment, training and support. The provider’s audit process was not robust, lacked detail and had not identified shortfalls in practice. Care records and monitoring charts had not been completed fully or in enough detail, with some containing incorrect or contradictory information. Medicines had not always been managed safely. Safe recruitment processes had not been followed consistently. We were not assured the provider’s induction process was robust and supervision had not been provided in line with the providers policy.

Accidents and incidents had been documented with actions taken. Some lessons learned had been considered, though this process needed to be completed more widely. Overall, safeguarding concerns had been logged and reported to the local authority, although we identified one issue which had not been, although it met the criteria. Enough staff were deployed to meet people needs. Shortfalls were covered by existing care staff or agency carers.

Assessment processes were in place, to ensure the home was suitable and could meet people’s needs. People had access to a range of professionals to help them stay well. Monitoring of care was inconsistent, with gaps noted in charts and some processes, such as weighing people, had not been completed in line with guidance. Verbal consent was sought from people prior to delivery of care. However, the process for seeking written consent needed improving, as did the provider’s adherence to the Mental Capacity Act 2005, where people lacked capacity to provide consent.

People’s views were sought via surveys and meetings, with a system in place for feeding back actions taken. Staff told us they would feel comfortable speaking up, and there was guidance in place on how they could escalate concerns, should they not feel listened to.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.

During an assessment under our new approach

Date of assessment: 14 to 29 January 2025. Heaton House Care Home is a residential care home, registered to support up to 21 older people, including those living with dementia. The assessment included 3 site visits, with additional information and evidence reviewed remotely. We have rated this service requires improvement. The assessment was completed to check if improvements had been made following our previous assessment in September 2024, where we identified 4 breaches of legal regulations. At this assessment we found continued breaches of legal regulations relating to good governance. Medicines were not managed safely. Governance processes had not identified all issues we identified, audits required adapting to ensure they were fully effective, and record keeping was not always contemporaneous or accurate. The provider was previously in breach of legal regulations relating to safe care and treatment, premises and equipment and staffing. Improvements were found at this assessment and the provider was no longer in breach of these regulations. As issues with medicines were largely related to record keeping, they now fall under good governance, rather than safe care and treatment. Risks relating to the environment had been adequately assessed and mitigated. Staff received sufficient training, support and supervision, to ensure they could carry out their roles safely and effectively. Improvements had been made with activity provision, seeking people’s views and involving them in their care. The provider was also now formally assessing how many staff were needed to meet people’s needs safely, which had resulted in an increase in staffing levels. We received positive feedback about the current home manager and the work they had done to make improvements. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

During an assessment under our new approach

We carried out an assessment of Heaton House Care Home, which is a residential care home, registered to support up to 21 people. At the time of this assessment 14 people were living at the home, although 2 people were currently in hospital. The assessment took place between the 25 September and 17 October 2024. The assessment included 2 on-site visits, with additional information and evidence reviewed remotely. The assessment was completed to check if improvements had been made following our previous assessment in March 2024, when we had taken regulatory action due to identifying 6 breaches of legal regulations.

At this assessment we found 4 breaches of regulations in relation to medicines, premises and equipment, good governance and staffing. Medicines were not managed safely. Risks relating to the environment had not been assessed timely or fully. Governance systems and audits were not fully embedded and had not identified all areas for improvement. Staff training and supervision records did not provide assurance these had been completed in line with the providers policy and procedures. The provider had made improvements since our last inspection and are no longer in breach of regulations 9 and 19. A more consistent activity programme was being provided which people enjoyed. Staff were recruited safely, with required employment checks being completed.

The home had undergone a number of managerial changes since the last assessment. A new home manager had been appointed in July 2024 but was no longer employed and the previous deputy manager had left and been replaced. The current deputy manager was running the home supported by a director and the nominated individual. People and relatives commented on some improvements being made within the home over the last few months.

During an assessment under our new approach

Heaton House is a residential care home, without nursing care, providing accommodation for people who require nursing or personal care to up to a maximum of 21 older people. At the time of our on-site assessment there were 18 people using the service. We carried out our on-site assessment activity on 6 and 11 March 2024. We assessed 11 quality statements. We carried out this assessment in response to continued risks about the safety of the environment, to check the provider had followed their action plan and to confirm they now met legal requirements. At the last inspection we identified breaches of regulations in relation to safe care and treatment, premises and equipment and good governance. We issued warning notice's against the breaches relating to safe care and treatment and good governance. We issued a requirement notice against the breach relating to premises and equipment. We made recommendations regarding reviewing people's risk assessments, embedding a programme of activities, reviewing safeguarding procedures and the duty of candour. At this on-site assessment sufficient improvements had not been made. We identified continued breaches of regulations regarding medicines management, person-centred care, premises and equipment, good governance, staffing and fit and proper persons employed. People did not always receive person-centred care, which was appropriate, met their needs and reflected personal preferences. Medicines were not always managed safely; accurate and up to date record keeping was not being maintained The premises and equipment were not safe, and not properly and effectively maintained, which placed people at risk of harm. The provider failed to operate effective systems to assess, monitor and improve the quality and safety of the service, and ensure records were up to date and completed accurately. Limited improvements had been made regarding staff training and staff were not always recruited safely.

21 June 2023

During a routine inspection

About the service

Heaton House is a residential care home providing accommodation for people who require personal and nursing care to up to 21 people. The service provides support to older people some of whom had dementia. At the time of our inspection there were 18 people using the service.

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

People’s medicines were not always managed safely; record keeping and systems relating to the management, storage and administration of people’s medicines were inconsistent. The provider had recently lost a number of staff and had carried out rolling recruitment; however, in some cases there were gaps in references and the correct service was not recorded on staffs DBS certificates; we discussed this with the provider who addressed this immediately. Risks relating to the safety of the environment had been identified but not actioned for significant periods of time. The provider was unable to evidence any actions to address risk identified in relation to the building. We identified the provider had not always responded effectively to safeguarding concerns. We have made recommendations relating to risk assessments and safeguarding procedures.

The provider and registered manager had not maintained oversight of systems and processes. There was no evidence of audits being carried out by the provider or registered manager which had led to a number of issues we identified during this inspection not being addressed. Audits which had been completed by other members of staff identified similar actions for a number of months without action being taken. The provider were not always clear on when notifications to CQC were required; however, we were assured this was due to a lack of oversight and governance as safeguarding referrals had been made and the provider had liaised with CQC. Staff reported feeling supported by the management team and felt confident changes being made would improve the service. We have made a recommendation the provider ensures systems relating to duty of candour are robust and effective.

The provider had not implemented systems which ensured staff were suitably skilled, qualified and had the relevant experience to provide care and support. Training records provided during our inspection did not provide assurances staff received robust training in all areas required. Additionally, staff feedback relating to their induction varied significantly and we found evidence within records which further corroborated this Information relating to people’s mental capacity had been recorded in care records and support plans; however, occasionally this was inconsistent and capacity assessments were not always decision specific. Communication with external professionals was not always recorded. We have made a recommendation the provider ensures all correspondence and involvement with external professionals involved in people’s care is recorded.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice .

The provider had not implemented a meaningful and varied programme of activities. We observed little evidence of people being engaged in activities and people and relatives feedback corroborated our observations. The provider had not always worked in accordance with their complaints policy; prior to our inspection the provider was made aware of a number of complaints. During our inspection we found only one complaint had been logged which meant an audit trail to evidence what action the provider had taken and when, could not be reviewed. Additionally, lessons learnt from complaints could not be evidenced due to their being only one complaint recorded. People’s care plans and support plans had been improved since our last inspection particularly oral care and communication plans. We have made recommendations in relation to activities and end of life care training.

People and their relatives felt care was provided by staff who understood how to meet their needs, promote their independence and dignity and protect their privacy. Staff demonstrated a good understanding of person centred care and how to support people as individuals. Staff told us this culture was apparent across the staff team and people confirmed this by describing staff as “kind, “hardworking” and “beautiful”.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 October 2022) and breaches of regulations were identified. The service remains rated requires improvement. Under the current provider this service has been rated requires improvement for the last two consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

At our last inspection we recommended that the provider reviewed training compliance, activities, people’s communication plans and their duty of candour systems. At this inspection we found improvements had been made to people’s communication plans; however, further development was needed in the other areas.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The inspection was prompted in part due to concerns received about the overall governance of the service, people’s safety and low staffing levels. A decision was made for us to inspect and examine those risks.

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

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, premises and equipment and good governance at this inspection.

We have issued warning notice's against the breaches relating to safe care and treatment and good governance. We issued a requirement notice against the breach relating to premises and equipment.

Follow up

We will request an action plan from the provider to understand 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

18 August 2022

During a routine inspection

About the service

Glenhomes Care Home is a care home providing personal and nursing care to up to 21 people. The service provides support to older people, some of whom are living with dementia and/or physical support needs. At the time of our inspection there were 16 people using the service. The service while registered to provide nursing care was only providing support to people with residential support needs and didn’t employ any nursing staff.

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

People and their relatives felt care was provided safely. Staff had a good understanding of incidents which would require a safeguarding referral and who they could and should contact if they had any concerns. Medicines were administered safely; however, some issues were identified in relation to audits, paperwork and night time medicine arrangements. Dependency levels had not yet been fully completed and some staff felt staffing levels at night were not sufficient. However, the provider had implemented new systems including an electronic recording system which would support the assessment of how many staff were needed to meet the needs of people. The home was clean and hygienic .

The provider had recently purchased the home from the previous provider and had identified several areas where improvement was needed. This included staff training and all staff had been assigned a training programme they needed to complete within a realistic timeframe. The provider evidenced their oversight of this. Staff had a good understanding of the MCA and how this impacted their roles. Inconsistent record keeping was identified across a variety of records, with some records not being completed appropriately or fully. We discussed this with the provider who demonstrated their new recording system which will promote consistency in record keeping. Training for staff on how to use the system had been scheduled. We have made a recommendation the provider continues to monitor staff’s compliance with completing mandatory training courses.

The provider had changed the layout of communal areas within the home to accommodate a bigger office. However, the provider had failed to consult with people and relatives and we fed back to the provider our concerns about the communal space available to the 16 people living at the service being limited. The provider advised they were in the process of purchasing the neighbouring property and communal space would be considered a priority when using this space to extend the home. They were unable to give a timescale of when any work would be completed.

People received care which was warm, attentive and person centred. People and relatives consistently shared positive feedback with us about their experience of the care provided at the home. People’s preferences, likes and dislikes were recorded in their care plans. Further detail was needed in some people’s records though to ensure all records reflected the person centred care provided by staff.

Care plans and risk assessments were completed to varying levels of quality; some people had plans which reflected how they wished their care to be provided and how staff could do this safely. However, some plans and risk assessments lacked detail. The new provider had set up a ‘meet the management’ meeting when they took over the home and relatives reported this being useful to them. However, some relatives felt communication since then could improve. We identified activities needed development and the provider acknowledged this and advised they had included this as part of an internal action plan. We have made recommendations the provider develops activities and continues to work to address the issues they identified when developing their own action plan.

The provider and management team had identified auditing systems were not robust. They had begun to implement new auditing tools and quality assurance assessments and development of these was ongoing. The provider had identified they needed to recruit a new registered manager for the service to address issues, gaps and inconsistencies they had identified following their purchase of the home. A registered manager had been interviewed and was due to start following a notice period. Following this the current registered manager would de-register and continue to be involved at a provider level. Not all relatives knew who the registered manager was with some referencing the deputy manager as ‘the manager’ and some referencing one of the directors of the home.

Aside from the stated failings in communicating changes to communal space people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection and update

This service was registered with us on 11 May 2022 and this is the first inspection.

The last rating for the service under the previous provider was requires improvement, published on 12 November 2019.

Why we inspected

The inspection was prompted in part due to concerns received about neglect, people being administered medication incorrectly by untrained staff and of concerns relating to support provided during night shifts. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

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 monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and good governance 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 from the provider to understand 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 continue to monitor information we receive about the service, which will help inform when we next inspect.