Heatherstones Court

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 Outstanding. This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 88 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

The service’s approach to learning clearly focused on improving outcomes for people. The provider promoted an excellent learning culture where people and staff were actively encouraged to report any concerns and suggest ideas for improvement. This highly positive approach ensured staff consistently reported all concerns and learning was shared across the staff team to ensure continuous safe practice. Comments from staff included, “If things go wrong we're not afraid to speak up, as we're not blamed. We are supported to look at what happened, how we can put things right and what we can learn from it” and “[Management] make sure [staff] are comfortable and have time to discuss things.”

The provider maintained a comprehensive overview of incidents, enabling them to identify patterns and trends. This included detailed incident forms that prompted staff to reflect on precipitating factors, the sequence of events, and post-incident outcomes. Evidence showed any learning from events was shared with the staff team and monitored to ensure improvements were implemented and maintained. For example, when the service experienced a number of medicine administration errors, the registered manager held discussions with individual staff and identified ongoing issues with the pharmacy. The registered manager arranged a meeting with the pharmacy where concerns were discussed and improvements agreed. Medicines procedures were also reviewed and updated. This resulted in a reduction in medicine errors.

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

The service has a strong culture of collaborative working and has implemented innovative and efficient ways to deliver care and support that is more joined-up for people, by actively working with other services.

From the person’s first contact with the service, the provider demonstrated their continual passion to ensure each person was at the centre of their care. Robust arrangements were in place so that care was discussed and planned with the involvement of people, their relatives and professionals. This consistent, seamless joint working approach continued throughout the person’s rehabilitation and through the discharge process. An example of this was a person who arrived at the service with complex health needs, which caused significant pain and affected their ability to manage personal care independently. They had also been living in an unsafe environment. The person wanted to regain their independence and live in a safe place. During their time at Heatherstones Court, the staff worked in partnership with health, social and housing professionals to ensure a coordinated and comprehensive approach to the person’s care. Through this multidisciplinary support and the consistent involvement of staff, the person experienced a significant improvement in their health and well-being. Their care needs reduced from 4 calls per day to a welfare call only. The person was discharged without a package of care and regained full independence and said Heatherstones Court “had saved their life.” This outcome reflects effective collaboration, safe care planning, and a person-centred approach that promoted recovery and restored autonomy.

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 shared concerns quickly and appropriately.

The provider had clear processes in place to manage safeguarding events. Staff had completed safeguarding training and understood how to recognise and report poor care and abuse. Incident reports were well completed and showed appropriate actions had been taken to protect people. Referrals had been made to the local authority safeguarding team and notified to the Care Quality Commission. A monthly log recorded all safeguarding incidents, including details of the incident, action taken and how lessons learned were acted on.

Staff had received training in Deprivation of Liberty safeguards (DoLS) and understood the processes to follow if a DoLS application was required. DoLS ensure if a person is restricted in a way that deprives them of their liberty in a care home, it is only done when it is in their best interests, is necessary for their safety, and all other options have been considered.There were no DoLS in place at the time of our assessment.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s health and safety were effectively assessed, monitored and mitigated. Person-centred risk assessments were in place and regularly updated, ensuring staff had the correct information to provide safe care and support. Staff we spoke with knew people well and were aware of people’s individual risks and how these should be managed.

The provider promoted a positive risk taking and least restrictive approach to risk management, involving people in decision making. Technology was utilised effectively. For example, a falls pendant, personal headset listener and vibrating smoke alarm were in place for a person with a sensory impairment.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was well maintained and tidy. Up to date safety certificates were in place and compliance checks were carried out regularly to ensure the safety of the building, equipment and technology.

A fire safety risk assessment was in place and recorded fire safety checks were up to date. Information required in the event of an emergency such as personal emergency evacuation plans (PEEPs), business continuity plan, fire book and keys was available. People were assessed prior to admission to ensure they could safely evacuate the premises in the event of a fire at night when there were no staff on the premises. Fire alarms were linked to the out of hours care control centre alerting them if the alarm was activated. People and staff were involved in regular fire drills.

Staff confirmed they had received training in health and safety and how to use equipment safely.

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

The provider had an excellent induction and training programme for staff which included mandatory and specialist training. Heatherstones Court is a reablement care service and training is tailored to enable staff to support individuals in achieving their maximum potential in terms of physical, emotional, and social well-being. The effectiveness of the induction and training was continuously reviewed to ensure improvement. Staff praised the training and support they received, saying it had given them the skills to carry out their roles and had been highly effective in supporting their development and confidence. Their comments included; “I’ve worked in care before and never had an induction like it. It lasted 5 weeks, nothing was rushed and I was given time to take information in, ask questions and digest information. I was given time to read through people's care plans and really get to know them. I did some shadowing with the community reablement team which gave me additional insight. This is the first job I've had where I feel prepared” and “Training is very good, more than I’ve had anywhere else I’ve worked. Best service I have worked in due to the support we’re given. I feel empowered to make decisions and very involved in people's care.”

Robust recruitment processes were in place. The provider consistently ensured staff were recruited based on their values of putting people first. They had a highly supportive culture which enabled staff retention. This meant people had continuity of staff and built excellent working relationships. Feedback from people consistently showed this was vital to meeting their needs and enabling them to achieve their full potential. Comments included, “[Staff] work beautifully as a team, all carers are in it together”; “Staff put more than 105% into their work. Eight weeks ago I could hardly walk, now [staff] gave me confidence” and “All the staff have enabled me to live a normal life.”

The provider had highly effective staffing systems in place which were flexible and could be adapted to ensure there were sufficient staff to meet people’s needs. This specialist service was designed to help people adjust after being in hospital and to regain independence in a community setting. The service does not provide 24-hour staffing. Staff were available on site between 8am and 10pm and out of these hours people had access to an emergency response centre via Careline. People could only be referred to the service if they were able to have their needs met by the emergency response centre overnight. Pre-admission assessments carried out by the service ensured this criteria was met. People’s dependency was thoroughly assessed prior to admission and throughout their stay. The provider ensured staffing was sufficient to meet people’s needs, giving staff enough time to support and promote people’s recovery and independence. The registered manager said if additional staff were required due to a person’s needs, then this would be facilitated. Staff feedback confirmed this approach and one staff member said, “They're flexible with the staffing and increase if people's needs are high.”

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

The provider had effective systems in place to assess and manage the risk of infection. Cleaning schedules ensured apartments and equipment were kept clean throughout people’s stay and a full deep clean was completed following discharge. Equipment was provided for the sole use of individual guests to avoid cross contamination. When guests were discharged, equipment either went with them or was thoroughly cleaned, quarantined for over 72 hours, and returned to the central equipment store. Each guest was provided with their own laundry bags. Laundry processes minimised infection risk through maintenance of machine filters, ensuring contaminated items were washed on hot cycles and each guest’s clothing was washed individually and not mixed with others.

On admission, COVID-19 and flu vaccination statuses were checked, with consent and refusals documented and GPs informed. Where guests request further vaccinations, consent forms were completed, and vaccinations arranged. Infection-related care plans and risk assessments were in place and reviewed regularly.

All staff completed hand hygiene and IPC training, with regular updates. Plentiful supplies of PPE were available and maintained. We saw staff wore PPE appropriately. Monthly IPC audits were thorough and provided evidence showing any required actions were completed. The most recent local authority IPC inspection took place on 26 June 2025 scoring 95% compliance.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff worked creatively with people, looking at ways in which to promote independence and enable individuals to reach their maximum potential in managing and administering their medicines. For example, one person, admitted following major surgery, required staff to administer their medicines, however, they wanted to be able to do this independently. Staff worked with the person and partners to enable this, resulting in the person being able to administer and order their own medication.

Improvements had been made since the last inspection. Spot checks and weekly audits ensured stock balances were correct and medicines had been given safely. Medicines policies and procedures had been reviewed and updated. Safe systems were in place for the ordering, storage and disposal of medicines. Medicine administration records were well completed and clear person-centred protocols were in place for ‘as required’ medicines.

Staff had received training in how to administer medication safely and had their competency assessed. One staff member had not been involved in medicines administration before they came to the service. They said the medicines training they received was very thorough and included extensive shadowing, competency checks and full discussions with management before being able to administer medication by themselves.