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Heron Hill Care Home Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 4 April 2019

About the service:

Heron Hill Care Home provides personal and nursing care for up to 86 people. The home is on three floors and arranged into three units. Nightingale is a general nursing unit on the ground floor, Cavell on the first floor is for people living with dementia and with nursing needs. There is a small male only unit, Wheawall unit, accommodating up to 20 men on the second floor. All units have separate dining and communal areas. All bedrooms are single occupancy and have ensuite facilities. At the time of our inspection there were 67 people living in the home.

People’s experience of using this service:

•We found that there were systems for assessing and managing risk but these were not always monitored to make sure the system was being as effective as it could be. Aspects of medicines management had not been monitored to make sure staff were following the correct procedures and that lessons learned were being disseminated to all staff. We have made recommendations about this.

•The service did not have a registered manager in post. The registered provider had acted quickly to put an interim manager in post to try to provide continuity following the unexpected loss of the previous registered manager. This appointment did not appear to have been effective and we found management oversight had been inconsistent.

•The provider had safeguarding systems in place and staff received training on this. We noted two instances of unexplained bruising that had not been reported to the management team. To help make sure safe practices were being used to reduce the risk of any bruising an occupational therapist reassessed people with specific moving and handling needs to help reduce this risk.

•High numbers of agency staff were being used to maintain safe staffing levels. The registered provider was actively recruiting and several new care staff were due to start following security checks. There was sufficient staff on the rotas to support people but some people were not always monitored by staff in line with their risk assessments to ensure their safety. The service was engaged in recruiting permanent staff and had thorough recruitment process to help ensure new staff were suitable to work with the people who lived at Heron Hill Care Home

•The registered provider had procedures for assessing a person's mental capacity in line with the Mental Capacity Act 2005. However, we found some inconsistencies in the recording of some people’s capacity assessments and some restrictions placed on them. We have made recommendation about this.

•Some staff training was overdue for staff including medication competencies. The management training analysis had identified some staff needed updates on training. The training plan covered the required training and was scheduled and organised to take place within the next two weeks.

•Everyone who lived at Heron Hill Care Home had nutritional risk assessments completed to identify their needs and any risks and people had been appropriately referred to their GP or to a dietician. However, we noted some supplementary records of food and fluids taken were not always being completed accurately to ensure accurate records. Some records we looked at had not been dated, so it was unclear if they were up to date. We have made a recommendation.

•A limited range of activities were available at the time of the inspection. We found some people who were being nursed in bed or had limited communication were at increased risk of becoming socially isolated. We have made a recommendation.

•Risk assessments relating to the environment were in place and to provide guidance and support for staff to provide appropriate care.

•Staff employed were supplied with personal protective equipment for use to prevent the spread of infections. Staff had received training in infection control.

•People were supported to maintain their independence. Staff took appropriate actions to protect people's dignity and privacy.


Inspection areas


Requires improvement

Updated 4 April 2019

The service was not always safe.

Details are in our Safe findings below.


Requires improvement

Updated 4 April 2019

The service was not always effective.

Details are in our Effective findings below.



Updated 4 April 2019

The service was caring.

Details are in our Caring findings below.


Requires improvement

Updated 4 April 2019

The service was not always responsive.

Details are in our Responsive findings below.


Requires improvement

Updated 4 April 2019

The service was not always well-led.

Details are in our Well-Led findings below.