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Heathcotes Chesterfield (Loundsley House) Inadequate


Inspection carried out on 11 December 2019

During a routine inspection

About the service

Heathcotes Chesterfield (Loundsley House) is a residential care home for people with learning disabilities, and/or autism and complex mental health needs. The care is provided in a purpose-built home for 8 people. There were 7 people living at the home at the time of our inspection.

People’s experience of using this service and what we found

The outcomes for people using the service didn’t reflect the principles and values of Registering the Right Support. Choice and control were not central to support provided and some people had not consented to interventions used to protect them. The least restrictive options were not always used to protect people from harm. Risk was not managed to ensure staff received up to date guidance in supporting people. When incidents occurred they were not fully reviewed to learn from them and reduce the risk of recurrence. Staff had not received adequate training to support people with complex health needs.

Assessments were not always in line with best practise guidance and some plans were not in place to direct staff; for example, how to support people with their diet in a positive way. This increased the risk that they were not always receiving care and support which met their preferences. Some people had communication systems in place and others were being developed although it was taking a prolonged time.

The provider did not have adequate oversight of the home despite an internal review noting there were significant improvements required. Staff were working consecutive days without a break leading to low morale. They did not have confidence in the responsiveness of the provider. There had been limited improvements since our last inspection.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was requires improvement (published 7 March 2019)

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to risk management, safeguarding people from harm, staffing levels and support, consent to care and good governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Inspection carried out on 16 August 2018

During a routine inspection

Loundsley House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Loundsley House accommodates up to eight people in one building. On the day of our inspection there were 6 people living in the service.

We inspected the service on 16 August and 8 September 2018. The inspection visits were unannounced on both days. This was the first inspection of the service.

The service did not 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. A manager was in post and plans to apply to the Care Quality Commission for registration.

People had not always been kept safe through the use of effective care planning and risk assessment and management. There was not always sufficient trained staff who were given clear directions on how to care for people with complex needs. The provider did not always have systems in place to recognise when they could no longer meet people’s needs.


Staff were not always deployed in the best interests of people and they worked very long hours without a break. Records did not always reflect what was happening in the service such as staffing levels and staff hours worked. They had not always been supported in a manner that enabled them to learn and flourish as staff members.

Care plans were basic and they did not always give staff clear directions on how to care for people who had complex needs. This impacted on risk assessments as up to date information on risk was not always available. Due to the lack of consistent management communications were not always effective. Staff said they had improved with the appointment of the new manager.

People’s dignity was promoted and staff were caring in their interactions with people. However people's independence was not always promoted as there was not always enough staff to ensure they had an active social life at a time they wanted outside the service.

There was a complaints process in place. There was a quality assurance process in place. However it was not always effective and had not reflected the concerns raised during this inspection process. The new manager reviewed incidents and acted to reduce them.

The service was clean and fresh and there were processes in place to keep the service infection free.

Medicine was stored and administered as prescribed. People's consent to care was sought for daily personal care activities. 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. The provider was working in accordance with the Mental Capacity Act 2005 (MCA), and people had their rights respected in this regard.