Heaton House Care Home

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.

The service was in breach of legal regulations in relation to the management of people’s medicines, staff recruitment processes, training and support.

This service scored 59 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events, although lessons were not always learnt to continually identify and embed good practice.

Accidents and incidents had been documented on a log. This contained basic information about who had been involved, they type of incident e.g. fall, swelling to face, and whether a safeguarding alert had been made and CQC notified, via the statutory notification process. Additional information regarding actions taken and outcomes, was contained on the actual accident or incident form itself, which was completed on the provider’s electronic system. From what was documented, it was not always clear what actions had been taken to try and prevent a reoccurrence and/or reduce risk. For example, 1 person was reported to have tripped on a ‘step up’ whilst walking along the corridor. There was no information about action taken to ensure the person did not trip in the same area in future, or that the area had been assessed to ensure any trip hazards were clearly marked / identified.

The provider had considered and documented some lessons learned, though only for a small number of issues, rather than all incidents or accidents which had occurred. It was not clear what triggered completion of a lessons learned document, as these had not been done where falls or injuries to people had occurred but one had been completed due to staff leaving documents in the printer tray, rather than filing them away.

Complaints had been managed in line with policy. Records detailed the nature of the complaint, findings of the investigation and response provided.

The provider used a service action plan (SAP), on which any actions or areas for improvement were added. However, the majority of the entries on the SAP were either maintenance / décor related, or issues which had been identified by external professionals such as quality monitoring officers from Bolton Council or CQC. There was limited evidence the provider’s own systems and processes had identified shortfalls and learned from these to drive improvements.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had clear processes and systems for supporting people’s transition into and out of Heaton House Care Home. The majority of referrals were from the local authority, who provided detailed care plans which the care home used to review the persons background, needs and any risks and determine if the home was suitable. The provider then completed their own pre-admission assessment, usually via a face to face meeting with the person and/or their relative. All information gathered was used to complete the initial care plans and risk assessments.

When people required hospitalisation, either following an accident or for a planned procedure, the provider sent information about people’s needs, preference, medical conditions and medication regime. These are often referred to as ‘hospital passports’ and help to ensure continuity of care.

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

The provider had an up to date safeguarding policy in place, alongside local reporting guidance, to ensure staff knew how to report safeguarding concerns to the relevant local authority.

Referrals had been documented in a safeguarding file, with records detailing the incident and initial actions taken. However, there was limited information on file regarding outcomes and follow up actions. For example, records stated a person deemed to be at risk of financial abuse had asked if they could have an advocate. There was no evidence to show this had been followed up on.

We identified at least 1 incident for which a safeguarding alert had not been raised, despite information documented within the accident form suggesting abuse could have occurred. A person was found to have unexplained bruising to both their left and right arms. As the person had been unable to say how this had happened, and the bruising was significant, a safeguarding referral should have been made and an internal investigation carried out, to try and identify potential causes, however, neither had occurred.

Deprivation of Liberty Safeguards (DoLS) are an important part of the Mental Capacity Act 2005. They involve providers seeking legal authorisation from the local authority where they need to deprive people lacking capacity of their liberty. For example, preventing them from leaving the care home without support, or having keypads on internal doors which prevents free movement. DoLS aim to ensure that such deprivations of liberty only happen when it is necessary, proportionate and in the person’s best interests. DoLS applications had been submitted as and when required, with a log used to monitor applications and their outcome.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider ensured enough staff were deployed, however, recruitment processes were not safe or robust, and we were not assured staff received effective support, supervision and development.

Safe recruitment processes had not been followed consistently. For example, 1 staff member had received a negative reference from their previous employer. This had not been followed up on, nor had a risk assessment been completed, until 5 months after they commenced employment at Heaton House. Another staff’s Disclosure and Baring Service (DBS) check had indicated their details did not match and for the process to be redone. This had not happened, which meant the provider could not be assured this person did not have any convictions or cautions and it was safe for them to work at the home.

We also identified a number of record keeping issues and other anomalies which internal monitoring of the recruitment process had not identified. For example, records indicted 1 staff member’s ID was received 10 days before they actually applied for the job. Another staff member was listed as having commenced employment in April 2025, yet their induction booklet was dated January 2025.

Based on records in staff files and the matrix provided, we were unable to confirm supervision had been provided to staff in line with the providers policy, which stated they should receive 5 to 6 per annum. The matrix used to log supervision meetings was confusing and difficult to interpret, with dates not matching or being incorrect and did not evidence staff had completed the required number of meetings.

Staff told us they were happy with the training provided and felt enough was available. Upon commencing employment staff were required to complete a 2 day induction, with a checklist used to document this. From reviewing some completed checklists, we were not assured the process was robust. For example, 1 staff member’s checklist was all signed off on the same day, rather than over 2 days. On another staff’s checklist, day 1 of the induction process had been completed on 9 July 2025, but day 2 had not been signed off until 10 November 2025. Similarly, another staff member completed day 1 on 21 January 2025 but did not complete day 2 until 13 September 2025.

From reviewing the training matrix, completion levels for ongoing training were acceptable, with the majority of staff up to date with sessions required to ensure they could meet people’s needs. Face to face training, in areas such as manual handling and first aid had lapsed. This was because the management team were in the process of completing courses to allow them to provide these training sessions themselves, rather than have to pay an external company to do so. Although the provider had completed a risk assessment to cover this gap in training, they had not carried out any competency assessments in 2025, to assess staff’ knowledge and skills in these areas, to ensure safe care was being provided.

Enough staff were deployed to meet people’s needs in a timely way. The provider used agency staff to cover any gaps in the rota due to sickness of holidays. Where possible, the same agency carers were requested to help with continuity of care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Overall, the home was clean, with effective infection control processes in place. Toilets and bathrooms contained hand hygiene guidance, paper towels and liquid soap. Personal protective equipment (PPE) stations were located on corridors, which were well stocked. This ensured staff had easy access to what they needed. Waste was disposed of safely, using the correct coloured bags.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Instructions for medicines to be given ‘when required’, such as paracetamol, were in place and contained person-centred information. The provider’s electronic medicine recording system (eMAR) documented the time ‘when required’ medicines had been given. However, staff had not documented the outcome or effectiveness of these medicines following administration. We also noted, 2 people prescribed paracetamol had received doses of this medicine too close together.

People were able to spend time away from the home, and the provider supported people to have their medicines available when they did so. However, the provider did not always follow their own policy to ensure this was done in a safe way and that any such instances were appropriately risk assessed.

Care plans were in place to give staff information on how to look after people with certain health conditions. However, these did not always contain enough detail about how to manage any complications linked to people’s conditions. Some also contained contradictory information, which could affect staff’s understanding of how to meet people’s needs.

Medicines were stored securely and areas used to store medicines had their temperature monitored. However, when temperatures had been outside of the recommended range, staff had not always documented what, if any, action had been taken.

The provider completed medicines management audits; however, these had not been effective in identifying and addressing all of the issues we found during the assessment.

Medicines were managed by staff who had been trained and had their competency assessed.

Staff ensured records reflected when people had topical creams applied and thickening powder added to drinks to prevent them from choking.