Heanton Nursing Home

We found the following examples of good practice:

There were clear plans and policies about how the wing would be used to keep people safe.

The separate entrance would enable staff to arrive at work, follow donning and doffing procedures using a purpose built PPE and hand washing structure. They could then enter the wing, via a key code, without needing to access the main premises. A separate staff team had been sourced who would only work in the wing, including domestic staff. An area had been made to accommodate staff breaks adhering to social distancing.

All five rooms were clean and had separate laundry, waste and clinical waste bins. Equipment such as mobility aids, would be provided separately depending on each person’s needs and included on the domestic cleaning schedule. The wing was able to be well ventilated and there was a large communal area which enabled social distancing.

Each room had been equipped for a comfortable stay and would also include televisions. Each person would have a family and friends contact form and be supported to use technology and phones to maintain regular contact with them. Additional wifi receivers had been sourced. There would be a brochure explaining visiting guidelines.

There were regular people and staff testing programmes in place. Contingency and admission plans were clear and included easy access to the wing by people arriving in an ambulance.

Safe procedures were known by staff to minimise the risk of transmitting Covid-19. Staff had received training on donning and doffing and on the coronavirus pandemic from various sources including local health and social care professionals, e-learning and from in-house training sessions. There were good stocks of all personal protective equipment (PPE). There were supplies of PPE available around the wing.

Heanton is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Heanton accommodates up to 52 people in one adapted building. The service is divided into three separate units which the service calls ‘houses’ by the name of Watersmeet, Exmoor and Williamson. Williamson is on the ground floor and caters for people living in the earlier stages of dementia. Also on the ground floor is a smaller house - Exmoor. This caters for people with complex needs due to their dementia needs. Upstairs there is one house - Watersmeet for people living with dementia who were in a repetitive stage or advanced stage of their dementia. The provider has developed and implemented this care model based on the household model of care pioneered in the USA by LaVrene Norton, Action Pact and Steve Shields. At the time of the inspection there were 51 people living at the service.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff offered care and support which is exceptionally caring and compassionate. People mattered and staff had a detailed understanding of people’s likes, preferences and wishes. People were asked to think of a wish and staff went out of their way to achieve this. Some staff came in on their day off to take people out for trips and meals out. Staff visited people in hospital in the own time, to keep in contact and show they cared. Staff knew people and their families well and worked in a person centred way.

The visions and values were imaginative and people were at the heart of the service. The registered manager and senior leaders led by example. The service was really well led and creative in the way they developed the service. They had developed bespoke training which gave staff the enthusiasm to embrace their vision and values to provide a family and home like environment where people felt safe and loved. This was evident in our observations, in records and in the way staff spoke passionately about people. There were strong links with the local community. The management team looked for ways to ensure people, their family and staff were involved in the running and improvement of the service.

The service was exceptional at helping people to express their views so that all staff understood their views, preferences, wishes and choices. They did this by ensuring staff had the skills to understand and interpret people’s complex ways of communicating.

There were sufficient staff with the right skills and understanding of people’s needs and wishes. Some concerns had been expressed following the inspection about insufficient staff on duty. The provider was open and honest in identifying there had been times when they had been short on their preferred numbers in the last month or so. However, the provider, registered manager and staff team all agreed that people’s needs and safety were not compromised due to staff shortages because of sickness. People and their relatives said staff were exceptionally kind and helpful. Our observations showed staff respected people’s dignity and privacy and worked in a way which showed kindness and compassion. This indeed where people were nearing the end of their life.

Care and support was person centred and really well planned. Staff had good training and support to do their job safely and effectively. Activities were tailored to meet individual’s needs.

People were supported to have maximum choice and control of their lives and staff supported

them in the least restrictive way possible; the policies and systems in the service supported this

practice. People's consent to care and treatment was sought. Staff used the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and understood how these applied to their practice.

Risk assessments were in place for each person. These identified the correct action to take to

reduce the risk as much as possible in the least restrictive way. People received their medicines

safely and on time most of the time.

Staff understood about abuse and who and when they should report any concerns to. Recruitment practices were robust and ensured only staff who were suitable to work with vulnerable people were employed.

People enjoyed a wide and varied choice of meals. Mealtimes were relaxed and enjoyable for people.

Quality assurance processes and audits helped to ensure that the quality of care and support as

well as the environment was closely monitored. This included seeking the views of people and

their relatives.

We completed this inspection to check on the welfare and safety of people following an incident where one person had swallowed a harmful substance. We wanted to ensure this type of incident could not occur again and lessons had been learnt. We had also been made aware by the provider that one person had sustained an injury following a fall from their wheelchair. We wanted to check that people had up to date risk assessments and where appropriate staff were using a lap belt on wheelchairs to help prevent people falling out of them.

The team inspected the service against two of the five questions we ask about services: is the service well led and is the service safe? This report only covers our findings in relation to this topic. You can read the report from out last comprehensive inspection, by selecting the ‘all reports’ link for Heanton on our website at www.cqc.org.uk

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

When we last inspected the service in April 2017 we focussed on one key question- Safe. This was because we had received some information of concern via the local safeguarding team. This information related to issues relating to infection control practices, people's care needs not being met, staff attitude, lack of respect and dignity and people being placed at risk from lack of hygiene and continence support. None of the concerns raised to the Local Authority Safeguarding Team were upheld. We observed people being treated with respect, dignity and the staff observed were caring and compassionate on the day we inspected. We did still rate this key question as requires improvement because we observed some key times in specific areas where there may not have been enough staff to meet people’s needs. We made a recommendation for the service to review the deployment of staff which they responded to. They reduced the number of staff taking breaks together so staffing levels remained consistent throughout the day.

Heanton is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Heanton is registered to provide care support and treatment for up to 52 people. At the time of this inspection there were 47 people living at the service.

They mainly support people living with dementia. The service is divided up into three houses. Williamson is on the ground floor and caters for people living in the earlier stages of dementia. Also on the ground floor is a smaller house- Exmoor. This caters for people with complex needs due to their dementia needs. Upstairs there is one house for people living with dementia who were in a repetitive stage or advanced stage of their dementia. The provider has developed and implemented this care model based on the household model of care pioneered in the USA by LaVrene Norton, Action Pact and Steve Shields.

Heanton has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Following the incident of one person swallowing a harmful substance, the provider had reviewed their policy and procedures to ensure this type of incident could not occur again. A harmful substance had been temporarily removed from a locked cupboard to a cupboard with a child lock. One person had accessed this cupboard and had put the substance in their mouth. They were found by a staff member. The provider has now put locks on all kitchen cupboards with the key being kept either in the nurse’s station or out of eye sight of people living at the service.

The COSHH process and policy has been updated to inform staff about where harmful products should be stored and what protocols to follow when using these. Staff have been made aware of these changes via handover meetings, team meeting and electronic notification. All of the staff we spoke to were clear about the changes made to COSHH and what they should do if this type of incident did occur again.

Where staff were using wheelchairs to transport people around the home, risk assessments had been used to show whether they were at risk of falling out of their wheelchair. Where risks were identified, staff were instructed to use a lap belt. In the incident reported to us by the home, the person concerned had previously showed distress and anxiety when a lap belt was used. The service judged they were not at risk of falling out of their chair because they did not present with jerky movements and there was no history of slipping out of chairs. Following the incident of them slipping out of their chair, staff have been instructed to use a lap belt at all times for this individual.

Lessons learnt from these two incidents have been shared across the organisation. This included policy changes and changes to risk assessment processes.

There was sufficient staff available to meet the needs of people who lived at the service. People were kept safe because the provider had robust recruitment processes. Staff were only employed once checks and references had been obtained to ensure they were suitable to work with vulnerable people.

Staff understood how to keep people protected because they knew the types of abuse to watch out for and who and when to report their concerns.

People’s care was well planned and risks had been assessed.

This inspection was unannounced and took place on 24 April 2017 in response to some information of concern received by the local authority safeguarding team. This information related to issues relating to infection control practices, people’s care needs not being met, staff attitude, lack of respect and dignity and people being placed at risk from lack of hygiene and continence support. None of the concerns raised to the Local Authority Safeguarding Team have been upheld. We observed people being treated with respect, dignity and the staff observed were caring and compassionate on the day we inspected.

This report only covers our findings in relation to the areas of concern identified in the information of concern we received. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Heanton Nursing Home on our website at www.cqc.org.uk.

When we last inspected on the 3 and 6 February 2017 we rated the service as overall ‘requires improvement’ with two breaches in regulation. These related to safe care and treatment. In particular we identified issues in relation to the safe storage of medicines and accuracy of records of medicines administered. We had also observed one incident where a person had not been fully supported to prevent their risk of choking. We also issued a requirement in relation to good governance. We found that although audits were in place they had not picked up on some of the environmental issues we identified and there had not been medicine audits for six months. We asked the service to send us an action plan to show how the breaches in regulation were going to be met and what improvements they intended to make. We received this action plan within the timescales requested. At this inspection we checked compliance with regulation 12, safe care and treatment and found this was met. We did not check on regulation 17, good governance, as we judged there to be insufficient time to enable the service to demonstrate that their audits and quality assurance improvements were embedded. This was because it was less than two months since the last comprehensive inspection took place. As part of this inspection we did review and discuss audits relating to medicines and dignity as these were areas we were reviewing at this inspection.

Heanton is registered to provide nursing and personal care for up to 52 people. They mainly support people with dementia. At the time of this inspection there were 46 people living at the service.

The provider has developed and implemented a care model based on the household model of care pioneered in the USA by LaVrene Norton, Action Pact and Steve Shields. This had resulted in the environment being divided into smaller houses to support small group living. Groups were determined based on the stage of the dementia of the person living at the home. There were four 'houses' (distinct areas within the building) which provided care for people at early stages of dementia, and people living with dementia who were experiencing an altered reality. The third area was for people who were living with dementia who were in a repetitive stage and the fourth house was designated for people who were living with advanced dementia. The provider had implemented this model with the support of specially recruited dementia practitioners. This implementation was still work in progress with staff still learning about the model of care and the environment still being adapted to suit each of the houses.

The service had a manager who was in the process of registering with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

Since the last inspection the provider has introduced a new ‘housekeeper’ role at the service. There were two housekeepers, one on each floor. Their role was to have oversight at mealtimes and throughout the day to ensure people have what they need. They also ensured people were fully supported to prevent the risk of choking when eating. This appeared to be working well, the home had employed staff specifically for this role. Specific staff members took this role during the week so at present an allocation was made at weekends within the rota to ensure there was a staff member who oversaw the meal time experience. The provider has informed us that as either existing staff members or new employees are identified and or recruited with the right attitudes and values this role will be individually rostered seven days a week.

Staffing levels in some areas of the home needed to be reviewed. Since feeding this back to the service, they have made some changes to the way staff breaks are taken. They now ensure only one staff member takes their break at a time. This meant once people have had their lunch, staffing levels remained consistent. We heard from the provider that this change had already had a significant positive impact for people living in the two houses upstairs. The deployment of staff in some area of the home needed to be reviewed, including in Tarka where people were living with complex needs. The provider agreed they needed to review the deployment of staffing in this and other areas to ensure they had the right balance of support for people at key times. We have made a recommendation about ensuring the deployment of staff is reviewed.

People were protected by safe medicines management. Medicines audits were being completed and there was a good audit trail of medicines and when they were being received and administered. Checks were being kept on the temperatures of where medicines were being stored.

People were protected against the risks of infection control. This was because infection control procedures were being followed by staff. We found no current evidence to support the allegation that there was poor infection control. Information received prior to this inspection stated that there were times that dog faeces and urine had been left on communal areas. The provider and manager agreed this was unacceptable and had taken actions to ensure this would not occur again.

People were being supported by staff in a kind and caring way. We saw people’s dignity and privacy being upheld. However we found some support plans lacked detail to ensure staff knew the strategies in place to ensure people’s dignity was maintained. Clarity in support plans was also needed to ensure people’s behaviours were managed safely and consistently.

This inspection was unannounced and took place on 3 and 6 February 2017. There were 44 people living at the service. When we last inspected on 14 November 2016, in response to some concerns raised by family whose relative lived at Heanton, we found a number of areas where improvements were needed. This included environmental issues and support and supervision of staff to ensure they had the right skills. Following the November focussed inspection we met with the provider and their management and quality assurance team on 18 January 2017 to discuss the improvements needed and future actions to be taken by the service. This included a discussion about how they had prioritised ensuring people’s clinical needs were being met and that people were safe. The provider and the staff team are now working on implementing their new model of care via a year long training course to enable staff to understand the culture and ethos of the household model. The provider sent us an action plan showing how they intended to make improvements as detailed within the previous inspection. We used this information as part of this inspection to check how well embedded any new ways of working were and whether this had impacted on the quality of care and support people were receiving.

Heanton is registered to provide nursing and personal care for up to 52 people. They mainly support people with dementia.

The provider has developed and implemented a care model based on the household model of care pioneered in the USA by LaVrene Norton, Action Pact and Steve Shields. This had resulted in the environment being divided into smaller houses to support small group living. Groups were determined based on the stage of the dementia of the person living at the home. There were four 'houses' (distinct areas within the building) which provided care for people at early stages of dementia, and people living with dementia who were experiencing an altered reality. The third area was for people who were living with dementia who were in a repetitive stage and the fourth house was designated for people who were living with advanced dementia. The provider had implemented this model with the support of specially recruited dementia practitioners. This implementation was still work in progress with staff still learning about the model of care and the environment still being adapted to suit each of the four houses.

There was a manager in post who had been the interim manager since July 2016, but had only just put in an application to register with CQC. She had previously been approved as the registered manager at this service, but made the decision to deregister at the start of this year. This was because she had, at the time wanted to take a more hands on role within the home. She said she now felt ready to take on the responsibility of being the registered manager again. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We found there were improvements needed with the safe storage of medicines to ensure they were being stored at the correct temperatures. We were told at the time of the inspection that medicine management had not been audited for up to one year. The provider has since said audit records show there had been some medicine audits but not as frequently as they should be. There were some gaps in the medicine administration records (MARs) which had not been picked up. Supervision records showed the manager had noted gaps in the way as needed medicines had been recorded, but this had not led to a full audit. We heard how two nurses were taking on the lead role of medicine management, which would include audits and quality checks in the near future.

We observed one occasion where, although staff were present there was no oversight on safety during the lunchtime meal. One person who was at risk of choking helped themselves to food and drink which was not suitable or safe for them to have and this resulted in them having a choking episode. We fed this back during the inspection and was assured this was immediately addressed. The provider said they were now having a member of staff in each dining area who was appointed to have an oversight on what each person was given or had access to eat and drink. On the second day of inspecting we saw lunchtimes appeared more organised with regard to ensuring people had the correct meals in a timely way.

There were still some improvements needed to make the environment suitable and comfortable for people. For example, some of the downstairs lounge chairs had an unpleasant odour and were in need of a deep clean. Some bedroom doors still had star locks which although not in use, should not be on doors. Two new bedrooms had been created; the radiators had not been covered to protect people from possible burns from hot surfaces. The star locks had been removed and radiator covers fitted by the following day of the inspection being completed.

Some parts of the home require further refurbishment. However, we also saw some good improvements since the last inspection. The lounge carpet in Bideford lounge had been replaced which had had a big impact on making the room more pleasant, homely and fresh smelling. The corridor between Bideford and Chichester had been extended out by means of knocking down some smaller rooms off the corridor. This had allowed the service to develop an alcove with further seating for people to use. This had also reduced the amount of incidents in this area. Audits of accident and incident reports had showed a reduction in incidents since this additional space had been created. This structural work had impacted in a really positive way and enhanced the living environment.

Care and support was being delivered by a staff group who had the right skills and training. There were sufficient numbers of staff on each shift to ensure people’s needs were being met in a timely and responsive way. Each house had at least two to three staff available each shift. In addition there was always one trained nurse and on some days two. Care and nursing staff were supported by a team of housekeeping and maintenance staff as well as chefs and kitchen staff. Staff reported there were sufficient numbers of staff each shift unless there was short notice of staff sickness. Relatives said they had noticed an increase in staffing numbers and were confident people’s needs were being met in a timely way.

Staff understood how to support people who were at different stages of their dementia. The household model was working well to promote people’s well-being and help staff develop their skills further. For example two staff who worked with people in the later stages of dementia had begun specialist training in best practice for end of life care. This was being completed in affiliation with the local hospice. All staff were being asked to complete a comprehensive induction book irrespective of how long they had worked at the service. This was to ensure all staff understood and were working within the framework of national standards as set by the Care Certificate.

People mattered and staff cared for people in a way which showed empathy, kindness and respect. We saw many examples of staff working with people to reassure them when distressed, providing a hug and talking to people in a compassionate and caring way.

People were supported to express their views and were involved in decision making about their care where possible. Staff understood the importance of offering people day to day choices. For example at mealtimes showing people both main meal options and asking them to choose which one they wanted.

Staff sought people’s consent for care and treatment and ensured they were supported to make as many decisions as possible. Staff confidently used the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Where people lacked capacity, relatives, friends and relevant professionals were involved in best interest decision making.

People were protected because staff understood what might constitute abuse and who they should report their concerns to. Safe recruitment processes were followed to ensure only staff who were suitable to work with vulnerable people had been recruited.

Care and support was well planned and risks had been assessed so that staff worked in the least restrictive way. People’s healthcare needs were well met and staff understood how to support people with changing healthcare needs.

People were supported to enjoy a balanced diet with flexible food and drink options available throughout the day and night.

Systems and audits were being used to help improve clinical outcomes but these had not included medicine management or identified issues in relation to the environment

There were two of breaches of regulations. You can see what action we took at the end of the report.

This inspection took place on 14 November and was unannounced. Prior to this inspection, we completed a comprehensive inspection in April 2016 where the services was rated as overall good, with requires improvement in safe. This was because we identified improvements were needed to ensure the environment was safe and met people’s needs. We did not issue any requirement notices at this inspection. We had assurances from the provider that the areas we identified as needing improvement had been addressed or were being addressed. We also completed a focussed inspection in July 2016 as a result of receiving some information of concern about one person’s needs not being met and them being in a room which was too hot and described as being in a poor state of repair. The concern also detailed the one person appeared dehydrated and did not have access to drinks. We did not find evidence to show this was the case when we inspected in July. We found the room was suitable for the person and they had a call bell and access to drinks when needed.

Heanton is a registered to accommodate up to 52 people and provides personal care and support as well as nursing care. Most people using this service were living with dementia. At the time of this inspection there were 48 people living at the service.

The Provider has developed and implemented a care model based on the household model of care pioneered in the USA by LaVrene Norton, Action Pact and Steve Shields. This had resulted in the environment being divided into smaller houses to support small group living. Groups were determined based on the stage of the dementia of the person living at the home. There were four 'houses' (distinct areas within the building) which provided care for people at early stages of dementia, and people living with dementia who were experiencing an altered reality. The third area was for people who were living with dementia who were in a repetitive stage and the fourth house was designated for people who were living with advanced dementia. The provider had implemented this model with the support of specially recruited dementia practitioners. This implementation was still work in progress with staff still learning about the model of care and the environment still being adapted to suit each of the four houses.

There was a manager in place who was in the process of applying to us to become the registered manager. She had previously been approved as the registered manager at this service, but made the decision to de-register at the start of this year. This was because she had at the time wanted to take a more hands on role within the home. She now said she is ready to take on the challenge of registered manager again, so is re-applying to register with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

At this inspection we found not all areas of the home were fresh smelling. One of the upstairs lounges was malodorous and the provider agreed this may have been due to the carpet, which needed replacing. We found bedrooms were warm and comfortable, although two bedrooms had been converted from bathrooms to bedrooms and still had toilets in situ, but these were not screened off. The provider said in the feedback, they would address this swiftly. Some light bulbs were not working in the upstairs communal areas which meant lighting was patchy and not suitable for people living with dementia and sight impairment. We received information from the provider following the inspection to show that toilets have been removed from the bedrooms and they would be replacing the carpet in the New Year.

People’s needs were not always responded to in a timely or appropriate way. We heard one person calling out for a cup of tea and staff did not respond to this request. One person sat at the lunch table for a long period of time (15 minutes) without any meal being offered to them. A member of staff was sitting next to them assisting another person and did not notice or respond to this first person. We also saw examples of staff not anticipating people’s needs or behaviours and therefore not being proactive in their approach. Staff were not always present in communal areas to assist people and check people were safe. The manager and provider agreed the layout of Chichester house was such that currently people could be unobserved, although the household model requires the house leader or other member to be present in communal areas at all times. The provider said they are working on expanding the communal space in this house, but as an interim measure they would look at increasing the staffing to ensure people were safe.

Some staff were more responsive in their approach. We observed some good practice where staff were aware of people’s changing moods and anticipated their needs. In another dining area for example a staff member encouraged one person to sit with them and eat their meal. They provided on-going encouragement and support to ensure the person ate a small amount of their lunch.

Newer staff described a variable approach to their induction process, some describing a two day comprehensive induction with shifts shadowing a more experienced member of staff. Others described a shorter induction and none were aware of being asked to complete the Care Certificate, which is a national induction process following all key areas of care work. Similarly staff described variable accounts of whether they had on-going support and supervision to discuss their role and plan for their on-going learning. When we fed this back, the provider said they acknowledged they needed to improve their induction process and had a working party set up and had contacted another organisation who had achieved an outstanding rating to learn from their practice which was already embedded.

We will meet with the provider in the New Year to discuss the findings and their action plan. We will then carry out a comprehensive inspection in the near future to look all the five key questions.

We found the service was in breach of one regulation. You can see what action we told the provider to take at the back of the full version of the report.

After the April 2016 inspection we received concerns in relation to one person’s room and a possible negative impact from them being in that room. As a result we undertook this focused inspection, on 27 July 2016, to look into those concerns. This report only covers our findings in relation to this topic. Other aspects of the concern, relating to staff practice issues, were investigated by the provider. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk.

Heanton is a registered to accommodate up to 52 people and provides personal care and support as well as nursing care. Most people using this service are living with dementia. The Provider has recently developed and have begun to implement best practice care delivery based on the household model of care pioneered in the USA by LaVrene Norton, Action Pact and Steve Shields. This has resulted in the environment being divided into smaller houses to support small group living. Groups are determined based on the stage of the dementia of the person living at the home. There were four ‘houses’ (distinct areas within the building) which provided care for people at early stages of dementia, people living with dementia who were experiencing an altered reality. The third area was for people who were living with dementia who were in a repetitive stage and the fourth house was designated for people who were living with advanced dementia. The model of care is known as the household model. The provider has implemented this model with the support of specially recruited dementia practitioners.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of the inspection there was not a registered manager in post. The provider said they had interviewed prospective managers but the recruitment process was still not complete. Senior management in the organisation was overseeing the service, visiting some days, and there was a clinical lead overseeing the day to day running of the home.

Arrangements were in place for staff at the home to recognise and mitigate risks associated with hotter than average weather. However, the design of one person’s room meant there was probably little throughput of air, which may have led to the person using it experiencing discomfort.

People’s needs with regard to adequate fluid intake were met. People had drinks available to them and during the hot weather staff had encouraged people to take more fluids and exert themselves less.

People were offered a choice of room where possible. Where a small room was considered the safest option for one person, this had been arranged; they said they were happy with it.

The one room we looked at had a working nurse call system in place, a working smoke alarm and a few small holes in the wall. However they were not impacting on the person’s use of the room, which was temporary.

Heanton is a registered to accommodate up to 52 people and provides personal care and support as well as nursing care. Most people using this service are living with dementia. The Provider has recently developed and have begun to implement best practice care delivery based on the household model of care pioneered in the USA by LaVrene Norton, Action Pact and Steve Shields. This has resulted in the environment being divided into smaller houses to support small group living. Groups are determined based on the stage of the dementia of the person living at the home. There were four ‘houses’ (distinct areas within the building) which provided care for people at early stages of dementia, people living with dementia who were experiencing an altered reality. The third area was for people who were living with dementia who were in a repetitive stage and the fourth house was designated for people who were living with advanced dementia. The model of care is known as the household model. The provider has implemented this model with the support of specially recruited dementia practitioners.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of the inspection there was a registered manager in post, however she has decided to apply to deregister with the Care Quality Commission and instead take a more active nursing role within the home. There was an interim manager already in place who had experience of managing similar services.

At the time of the inspection there were 39 people living at the service. Some of the people who had been living at this service for some time had recently been moved to different areas depending on their needs in relation to their dementia. Some relatives spoke with us about their concerns about the moves for people. Some were still getting used to different rooms, floors and staff. One relative said ‘‘I understand why they have made these moves and I think it is a good idea, but I and (name of person living at the service) were used to being downstairs and knew the staff well.’’ Another gave a more positive view saying “I can’t fault the staff they are all lovely. They look after my relative and me for that matter in a very kind and caring way”

We found that although care and support was being well planned, details about whether someone’s liberty was being deprived and whether the service was operating under the principles of the Mental Capacity Act 2005, were less clear within the electronic care plans. Staff were not always aware of who may be subject to a Deprivation of Liberty safeguard (DoLS) or who had an application for such a safeguard awaiting approval. The senior managers agreed the care files were not explicit enough in this area but were certain staff worked within the main principles of ensuring people’s rights and consent was always considered in their everyday practice. We saw examples of care delivery which supported this. For example staff checked with people they were happy and understood what was happening, before providing support to them. Since the inspection the manager has provided evidence to show care electronic care plans now include whether DoLS have been applied for and/or authorised.

Improvements were needed to ensure the environment met people’s needs. We found some hot water outlets were running very hot which could have presented as a scalding risk to people. The provider had already identified this as an area to improve, and following our first day of inspection, called in their in-house plumber. They started work on ensuring all hot water outlets had a valve fitted to thermostatically control the hot water and therefore prevent possible risks of scalding. Tiles were missing from the corners of the platform which the washing machines stood on. This meant there were areas which could not easily be washed down to prevent cross contamination. The provider agreed to address this as a matter of urgency. Since the inspection we have seen evidence to show this was been addressed.

Whilst some of the communal areas of the home had been painted and/or decorated to provide a brighter and more stimulating environment for people, there were still areas of the home which were in need of refurbishment. We discussed this with the senior management team, who explained they had short and long term plans to address the whole environment, but that health and safety issues would be dealt with urgently and ascetic refurbishments would be an ongoing process. We found all areas clean and mostly odour free. On one day one of the lounge areas did not smell as fresh. When we fed this back the senior managers said they would organise for this area to have a deep clean that evening.

People were being supported by staff that understood their needs and worked alongside them to reassure and provide positive encouragement. For example one person was walking without obvious purpose asking for help to get the train back home. Staff talked and walked around with this person, suggesting they may need to wait for the ticket office to open, or they were not sure of the times of the train and perhaps they would like to have a cup of team whilst this was being sorted out.

Staff had received training in key areas to help them do their job safely and effectively. Ongoing support to staff had tended to be responsive but there were plans being put in place to ensure all staff had regular support and supervisions to discuss with a senior member of staff, how their work was doing and whether they had any future training needs.

There were enough staff with the right skills, available throughout the day and the evening to meet people’s needs. We heard from senior managers that when they were assessing new people to come to the service, they would be looking at their individual’s needs and what support they needed and this would impact on the numbers of staff they had for each shift. This meant they service would be using a dependency/needs tool to help ensure their staffing levels were right going forward. Staff said staffing levels had improved, although there had been odd occasions due to staff sickness when they had been short. The senior management team said they had recruited enough staff to be able to cover shifts and rarely needed to use agency staff unless in an emergency.

Recruitment processes ensured only people who were checked as being suitable to work with vulnerable people were employed. Staff understood safeguarding processes and how to protect people from harm. The service were working well with partner agencies to ensure people were being protected from harm.

Care was being planned in a person centred way ensuring staff understood people’s history, preferred routines and things that were important to them. Activities were planned throughout the day to ensure people had access to activities they enjoyed as well as time to rest and chat with staff. Community groups were encouraged to visit and play and active part in the activities of the home. For example church services were held on a regular basis.

People’s medicines were being safely managed and systems ensured their nutritional needs were being met.

The provider ensured the home was safe or that measures were being put in place to ensure safety. Audits were used effectively to review the quality of care and support being provided.