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Archived: Nelson Inadequate

Inspection Summary

Overall summary & rating


Updated 10 May 2016

We undertook an unannounced focused inspection of the Nelson branch on 3 March 2016. This was as a result of the Commission receiving additional information and further concerns that related to the care and welfare of people using the service. The concerns related to missed visits, administration of medication and delivery of the care provided. As a result we undertook a focused inspection to look at those concerns. This report only covers our findings in relation to those concerns. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for the location known as ‘Nelson’ on our website at

Nelson provides care and support for people in the Burnley and Pendle area. The range of services provided includes, personal care, domestic help and shopping. The service provides support for older people, people living with a dementia, adults with physical disabilities as well as learning disabilities. The agency's office is located in the centre of Nelson. The agency was known to people using the service as Heritage Homecare.

The Nelson branch was last inspected 24, 25, 30 November and 9 December 2015. This was as a result of the Commission receiving concerning information relating to the care received by people who used the service, staff leaving and visits being missed. As a result of this inspection a number of breaches of the Health and Social Care Act (Regulations Activities) Regulations 2014 were identified. The service was rated as inadequate and was placed into ‘special measures’.

During this inspection we identified ongoing breaches relating to safe care and treatment of people using the service. We are taking action against the provider and will report on this when it is complete.

As part of this inspection we visited the Nelson office as well as the head office in Lancaster where the call monitoring systems and the directors are based.

We saw evidence of missed visits taking place, the provider was in the process of transferring care packages to alternative care providers with oversight by the Local Authority. The Director of the Company could give us no assurance that people would receive the care visits that they required.

We received confirmation from the provider that staff at the Nelson branch had not been paid at the end of February. This has resulted in staff leaving and the Company’s continuing ability to meet the allocated visits for people using the service at the Nelson branch.

We were told by a Director that there had been a director who had been to the office on a number of occasions. However all staff spoken with told us the directors of the company had not visited the Nelson branch for approximately three weeks.

Inspection areas



Updated 10 May 2016

The service was not safe.

We saw evidence of ongoing missed visits taking place. The provider was in the process of transferring packages of care to alternative providers.

Staff told us the director who was responsible for the management of the Nelson branch had not visited the office for approximately three weeks.

We were told that staff had left their employment as a result of not receiving their wages.

We had no assurance from the Director of the Company that people would receive the care visits that they required.



Updated 18 December 2015

The service was not effective.

People were not provided with appropriate care and support to ensure their nutritional and hydration needs were met.

People expressed mixed views on their experience of the service. Some were satisfied with the service others were not.

Staff had not received suitable training and supervision to enable them to deliver care to people to an appropriate standard.

The service was not fully meeting the requirements of the Mental Capacity Act 2005.


Requires improvement

Updated 18 December 2015

The service was not always caring.

People made some positive comments about the caring attitude and approaches of staff. They indicated their privacy and dignity was respected. However, we were also told some carers were okay and some were not.

Care records were lacking in providing details of people’s individual background histories, relationship’s and cultural needs and preferences.


Requires improvement

Updated 18 December 2015

The service was not consistently responsive.

People were not always receiving a person centred service. The delivery of care did not meet their needs and reflect their preferences. Some people were dissatisfied with the lack of continuity in care workers.

There was a lack of satisfactory arrangements to review and respond to people’s changing needs and preferences.

People told us of their dissatisfaction with aspects of the service; some indicated they had raised concerns. However, we found concerns and complaints were not properly responded to and managed.



Updated 16 March 2016

The service was not well-led.

We saw that the call monitoring system used to ensure people who used the service provided inspectors with conflicting information. We were told by one person there were only two lines for staff to call in to however another said another figure. Records of visits undertaken to people were unreliable.

Monitoring of complaints was ineffective. A record of actions taken as a result of people’s complaints had not been completed. Although there was evidence that team meetings had occurred we could not see which staff had attended them or what actions were taken forward as a result.

We saw that only three people had been invited to provide feedback about the care they received from staff. There was no evidence to confirm what action the provider had taken as a result of the feedback. Care file audits had taken place but evidence suggested all seventy six of these had been completed on the same day by the same staff member.