Heaton House Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to audit and governance processes.

This service scored 62 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider’s policies and procedures supported their vision and values. Staff understood their responsibility to provide safe and effective person-centred care to people, in line with the provider’s values for the service.

Meetings were held with people and staff, which allowed them to share their views and be involved in the home and decisions made. The meeting agenda included a review of the previous meetings minutes and actions, so people and staff could be updated on any improvements made.

The provider produced and circulated a monthly newsletter, which detailed what had taken place within the home over the past 4 weeks, such as activities and events, along with information about people living at the home and staff members. Information was also displayed within reception on a large screen.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People, relatives and staff all told us they would feel comfortable to speak up and raise concerns. They all stated the home manager was approachable, and felt they would act on concerns raised, though no-one had yet needed to make a complaint.

The provider had up to date policies and procedures in place, which provided guidance for staff on how to speak up and raise any concerns. The provider had a comments and suggestions box within the home, where people, relatives or staff could post feedback or raise concerns anonymously, should they not wish to speak with the manager or the provider directly.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff were valued and treated equally and fairly. Staff received the same opportunities to learn and progress in their roles. Some staff we spoke with had progressed from a carer role into more senior positions. The staff handbook included a section on the importance of valuing diversity and dignity at work.

The provider promoted staff wellbeing and ensured all team members had access to support, information, and signposting to help them maintain good physical and emotional health. This included a dedicated staff wellbeing group, where they shared information, resources, and guidance to support mental health, resilience, and work–life balance.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s audit and governance process was not robust and had not been used effectively to identify issues and shortfalls in practice. A range of audits had been completed on a monthly basis, however, we were not assured these had been completed in a meaningful way to drive improvement and quality, rather than just be a tick-box exercise. The majority of completed audits stated compliance in the area being assessed was 100%. This included audits of recruitment files, care plans and risk assessments and nutrition and hydration, all areas where we identified issues during the assessment process.

Where auditing or quality monitoring processes involved observation of staff, or review of documentation such as staff files and care plans, no record of which staff had been observed, or which records had been checked had been kept. As a result, the provider had no way to track which staff and records had been checked and which still needed to be done.

Record keeping was not always accurate or contemporaneous. As mentioned elsewhere in the report, we found gaps in monitoring charts, records did not always accurately detail what people had eaten and drank, and some care plans contained inaccurate or contradictory information.

The provider had not consistently upheld their duty to notify CQC of certain incidents and events. When reviewing accident, incident and complaint records, we identified some notifiable issues which we had not been told about. One related to an allegation of physical abuse which was referred to and investigated by safeguarding. Another related to a person whose accident form stated they had sustained a hairline fracture of their hip, during an incident in the bathroom.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider shared a number of examples of partnership working and their involvement in the wider community. The home manager had worked with the company who provided their eMAR system, to help identify any shortfalls and ensure the product meet the needs of care home providers. We also saw examples of links and work with district nurses, and the care home pharmacist from Bolton’s NHS Foundation Trust, with the aim of improving care and people’s experiences.

People living at the home had access to the local community, with several attending outings, shopping trips and visits to friends and families independently.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.