SeeAbility - Heather House Nursing 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 good. At this assessment the rating has changed to 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.

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. Lessons were learnt to continually identify and embed good practice.

We observed staff listening to people and responding to their concerns. Staff knew what incidents to report and how to report them.

The service investigated incidents thoroughly and shared outcomes with people and relevant stakeholders. We saw evidence of change as a result of incidents which had occurred.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure the provider could take appropriate action to mitigate these risks.

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 an admissions policy in place. The registered manager was able to explain the process including assessing people’s needs to establish suitability, ensuring specialist equipment was available and staff had additional training if required.

People were consistently supported when they were distressed. There was a focus on planning for a good day and understanding what had caused people distress so positive changes could happen.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider mostly shared concerns quickly and appropriately.

People had access to easy read information, or staff who knew them well to help them raise concerns.

Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally.

The service mostly shared concerns appropriately by following the correct process and ensuring these were reported to the relevant agencies. We reviewed 1 reportable concern which had not been reported to the local authority safeguarding team. The concern related to a person being subjecting to an invasive procedure in error. We spoke with the registered manager about this, who sent a retrospective notification and informed us how they had tightened their processes to ensure this did not happen again.

Where restrictive practices were in place Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise, restrictions placed on people to keep them safe.

The provider worked well with people to understand risks, however, documents did not always contain accurate information. Staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them.

People were assessed for risks of falls, risk of choking and risks relating to medical conditions. We reviewed people’s care plans. Some care plans contained conflicting, or not enough information, for example, care plans relating to falls, epilepsy and fluid intake. Incomplete information increased the risk of people not receiving the right treatment. However, we were assured staff we spoke with knew people well. We spoke with the registered manager about this who was responsive and updated the care plans in a timely manner.

When risk had been identified staff used specialist equipment to monitor people’s health conditions.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

During our on-site inspection visit, we observed gaps in some fire doors. The provider was visited by Hampshire Fire Service on 17 September 2025. Following this visit, they were issued with a ‘Letter of fire safety matters’ which set out a schedule of fire safety improvements, which included the concerns we found related to the fire doors. Following this visit the provider completed a Fire Risk Assessment on 2 October 2025 which also detailed concerns with the fire doors. These concerns were recorded as ‘high severity actions.’ The provider’s action plan following this assessment detailed the work was to be completed by 2 January 2026. Whilst other actions had been completed, the work to the fire doors had not taken place. The provider took immediate action after we raised our concerns, which included additional checks at night and a change to the evacuation procedure whilst the works on the fire door was completed. Whilst we appreciated the responsiveness of the provider, we were concerned these actions had not been put in place upon receipt of the Fire Risk Assessment in October 2025. This had put people’s safety at increased risk in the event of a fire.

The provider did not have effective or robust fire evacuation procedures in place. We reviewed staff fire evacuation training records. During 3 evacuation practices, concerns were raised about a bed being difficult to manoeuvre in the event of an evacuation. We could not see evidence of how the risk of this had been mitigated.

These records did not evidence all staff had been involved in a fire evacuation drill. During 2 evacuation practices, concerns were raised about some staff’s lack of knowledge and action. We could not see evidence this had been raised with the staff members. We spoke with the registered manager about this who told us following our inspection visit, they had prioritised fire evacuation practices with staff and would be completing these daily to ensure they captured all staff.

The concerns we found with fire safety placed people at significant risk in the event of a fire.

The provider made sure there were enough qualified, skilled and experienced staff, who mostly received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Relatives told us there were enough staff and they felt staff knew their relatives well.

The registered manager had a training matrix in place which evidenced most staff had completed all of their statutory and mandatory training and competency assessments to ensure they were able to meet people's individual needs. The provider ensured staff attended bespoke training relating to supporting people with a learning disability and autistic people. Where staff had not completed training, they were booked onto a session.

The provider had recruitment processes which were fair and ensured there was no disadvantage based on any specific protected characteristic. The provider followed safe recruitment practices.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We inspected the kitchen, we found multiple food items which did not have labels on dating when the item had been opened, meaning the disposal date could not be calculated. We also found food items which had been incorrectly stored after opening. We observed some gaps in daily recordings of fridge and freezer temperatures. This meant people were at risk of being given unsafe foods. We spoke with the registered manager about this, to ask why this had not been picked up by them, they confirmed they had not been completing checks of the kitchen themselves but would add this to their environmental audit to ensure they did this moving forward.

The provider had a robust up-to-date Infection Prevention and Control (IPC) policy and staff attended IPC training.

We received mixed feedback from relatives about whether the home was clean. Some relatives told us the home was very clean, other relatives told us the cleanliness standards reduced on occasion.

We reviewed cleaning schedules which were consistently completed. We observed the home was clean.

The provider did not always make sure that medicines were stored safely. They did make sure treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning.

We reviewed stock control of stored medicines. We observed some stock counts which were not correct, either by too many or too few tablets. We found boxes of medicines which did not have the pharmacy prescription or name of the person. No longer used medicines were not always returned to pharmacy and instead remained in some people’s medicines cupboards thus increasing the risk of errors and harm to people.

There was a medicine policy in place. Staff received medication training, and their competency was checked to ensure they understood the requirements for the safe administration of medicines. Staff supported and involved people to manage their medicines. We observed a medicines round which evidenced this. Records showed people had received their medicines as prescribed.

The registered manager told us, during people’s annual health reviews, Stopping Over Medication of People with a learning disability and/or autism (STOMP) plans were reviewed. This ensured people’s medicines were reviewed to ensure psychotropic medicines were not inappropriately prescribed or overused. This meant people were less likely to be at risk of medical restraint.