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Heron Hill Care Home Requires improvement

The provider of this service changed - see old profile

Reports


Inspection carried out on 22 January 2019

During a routine inspection

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.

•People

Inspection carried out on 28 November 2017

During a routine inspection

We carried out this unannounced inspection on 28 and 29 November 2017. Our last comprehensive inspection of the home took place in April 2017. At that inspection we found breaches of regulations relating to the safety, effectiveness and quality of the service.

Following our inspection in April 2017 the provider developed a plan to make improvements to the service. During our inspection in November 2017 we found the provider had taken action to improve the quality and safety of the service. However we found further improvements were required to ensure people consistently received safe and effective care.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Heron Hill Care Home, (Heron Hill), 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.

Heron Hill provides accommodation and 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 and Cavell and McKenzie on the first and second floors care for people with dementia nursing needs. All of the units have separate dining and communal areas. All bedrooms are single occupancy and have en suite facilities. At the time of our inspection there were 64 people living in the home.

There was a manager employed at the service. The manager had applied to us to be registered. The manager’s application for registration was approved after we visited the service in November 2017. 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.

People were safe living in the home. They were protected from abuse and hazards to their safety had been identified and managed.

Improvements had been made to how medicines were managed and people received their medicines safely and as they required.

The premises and equipment were safe for people to use. Procedures were in place to protect people in the event of a fire.

People enjoyed the meals provided and were protected against the risk of unplanned weight loss. People received the support they needed to enjoy their meals. We discussed improving how meal choices were communicated to people living with dementia.

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. We have made a recommendation about consent for the use of equipment.

Care was planned and provided to meet people’s needs. Some care records held inconsistent information or had not been fully completed. However, the staff knew the support individuals required and provided this. We have made a recommendation about managing records.

People were protected against the risk of infection. We identified one issue where staff were unclear about if an item of equipment could be used by more than one person. We have made a recommendation about guidance for staff around use of equipment.

There were enough staff to support people. The provider assessed staffing levels taking account of people’s needs. The home provided nursing care and there were qualified nurses employed on each unit.

Although safe sys

Inspection carried out on 5 April 2017

During a routine inspection

This inspection took place on 05, 12 and 27 April 2017. Visits to the service on 05 and 27 April 2017 were unannounced; we told the provider that we would return to the service on the 12 April 2017. We last inspected the service on 05 and 06 December 2017 when the service was judged to be in breach of seven regulations.

During this inspection we reviewed the action taken by the provider to meet the requirements of the regulations, these included; safe care and treatment, including medicines management. Person-centred care. Need for consent. Safeguarding service users from abuse and improper treatment. Premises and equipment in relation to infection control and environment maintenance. Good governance and staffing.

At this inspection we found the provider was still in breach of the regulatory requirements for safe care and treatment, including the proper and safe management of medicines. Person-centred care. Need for consent. Safeguarding service users from abuse and improper treatment. Good governance and staffing.

We found that the provider had made some improvements, which are included in the main body of this report. The provider was no longer in breach of Regulation 15 in relation to premises and equipment.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. The purpose of special measures is to:

Ensure that providers found to be providing inadequate care significantly improve. Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made. Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider's registration to remove this location or cancel the provider's registration.

Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is over three floors and has three separate units. Each unit has a separate dining area and communal lounge. On the ground floor Nightingale Unit provides general nursing care; on the first floor Cavell Unit provides nursing care for people living with dementia and on the second floor McKenzie Unit provides care for males living with dementia.

There is a hair dressing room in the service. All bedrooms are of single occupancy and have ensuite facilities. The service provides support to adults who have a physical disability, mental health needs, behavioural support needs, dementia and complex nursing needs. One unit is a 20 bedded all male unit, for those who may present more challenging behaviours that need specialist input. At the time of the inspection there were 76 people living at the service.

There was a newly appointed manager in place who had applied to become a registered manager. The manager had been promoted from deputy manager and was being supported by the nominated individual during their induction period. The manager had submitted their application to CQC to become Registered Manager.

A Registered Manager is a person who has registered with the Care Quality Commission to manage the service.

Inspection carried out on 5 December 2016

During a routine inspection

This unannounced inspection of Heron Hill Care Home took place over two days on 5 and 6 of December 2016. We last inspected Heron Hill Care Home in July 2015.

At that inspection we found a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities Regulations) 2014 regarding the proper and safe management of medicines. We found that medicines were being not stored safely during medicines rounds and administration was not recorded correctly. We asked the provider to take action to make improvements. The registered provider gave us an action plan telling us how they were going to make the improvement by 31 October 2015.

There was also a breach of Regulation 9 (person centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because records for the management of medicines and creams did not contain sufficient detail to make sure that people received appropriate care. At this inspection we found that this had improved. Some people were prescribed emollient creams that were applied by carers when they helped people wash and dress. We looked at seven people’s records and found that carers were applying creams regularly

Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is over three floors and has three separate units and each unit had separate dining and communal areas. On the ground floor, Nightingale unit provided general nursing care, on the first floor, Cavel unit provides nursing care for people living with dementia and on the second floor is McKenzie an all male unit.

There is a hairdressing room in the home. All bedrooms in the home are for single occupancy and have ensuite facilities. The service provides support to adults who have a physical disability, mental health needs, behaviour support needs, dementia and complex nursing needs. One unit is a 20 bedded all male unit, for those who may present different or more challenging behaviours At the time of the inspection there were 78 people living in the home.

At this inspection 5 and 6 December 2016, we found that some improvements had been made to aspects of medicines management. However, the medicine storage and medicines monitoring that could have an impact on people living in the home continued to require improvement. This was a continued breach of Regulation 12 (safe care and treatment) of The Health and Social Care Act 2008 (Regulated Activities Regulations) 2014.

We found there were several other breaches of the regulations that could have an impact on the people who lived there. There was a breach of Regulation 15 regarding premises and equipment, a breach or Regulation 11 - Need for consent and of Regulation13 - safeguarding service users from abuse and improper treatment. There was a breach of Regulation 18 - Staffing, Regulation 9 - person centred care and Regulation 17 - Good Governance.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

Ensure that providers found to be providing inadequate care significantly improve

Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they

Inspection carried out on 20 December 2015

During an inspection to make sure that the improvements required had been made

This inspection took place on 20 December 2015 and was unannounced. We carried out a focused inspection after we had received concerns from other agencies and individuals in relation to the levels of suitably qualified staff being deployed in the home to meet people’s needs. As a result we undertook this focused inspection to look into those concerns. This report only covers our findings in relation to staffing. We have not revised the rating for this key question and the service continues to require improvement in this domain. We will review our rating for safe at the next comprehensive inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Heron Hill Care Home on our website at www.cqc.org.uk.

Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is on three floors and has four separate units each with separate dining and communal areas. All bedrooms are single occupancy and have en suite facilities. The service provides support to adults who have a physical disability, mental health needs, behaviour support needs, dementia and complex nursing needs.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.

We found on the day of our inspection 20 December 2016 and from looking at rotas and speaking to staff that staff levels fluctuated in the home and staff were at times being moved to work on different units with people whose needs they were not familiar with. We found that efforts were being made to recruit more permanent staff and that agency staff were used to maintain sufficient numbers of staff but that the skills and experience of people were not always being taken into account when staffing units. Work that had been done on using a dependency tool to assess and adjust staffing levels but the staffing was not consistent and stable across the home and the numbers of permanent staff were sometimes exceeded by agency staff on night shifts.

Rotas over the Christmas period indicated that all the units would have sufficient nursing and care staff on duty as long as all staff worked their shifts. On the day we visited sickness had reduced the staff levels and also the adverse weather conditions. There was no clear contingency in place and we recommend that the service finds out more about developing procedures for dealing with emergency situations when staffing levels drop below the accepted level which is likely to have an impact on care.

Inspection carried out on 17 July 2015

During an inspection to make sure that the improvements required had been made

This unannounced inspection of Heron Hill Care Home took place over three days on 17, 20 and 21 July 2015. During our previous inspection visits on 21 and 22 October 2014 and 11 May 2015 we found the service was not meeting all the regulations.

This was because at our inspection on 21 and 22 October 2014 there was not verifiable evidence that all staff in the home had received induction training, appropriate training for their roles or regular supervision and appraisal to monitor their performance. People living there could not be sure the staff caring for them had received appropriate training and supervision to meet their needs.

We also found at that inspection that people were not being protected against the risk of unsafe care because the registered provider had not made sure that all aspects of service provision and record keeping were being regularly monitored for effectiveness. We issued requirement notices to the provider that required them to make improvements in relation to staff training and supervision and the effective monitoring of records and service provision. The registered provider wrote to us and gave us an action plan saying how and by what date they would make the required improvements. They also told us how they would monitor this.

We also carried out an inspection 11 May 2015 following concerns raised by agencies and individuals regarding low staffing levels within the home. At this inspection we found that the registered provider did not have effective systems to ensure they consistently deployed sufficient numbers of suitably qualified and skilled staff to make sure that people’s care and treatment needs were always met. We issued a requirement notice that required them to make improvements in relation to this.

At this inspection17, 20 and 21 July 2015 we found that the registered provider had made the improvements needed to meet the requirement notices from the previous visits. However at this inspection we found that there was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities Regulations) 2014 regarding the proper and safe management of medicines. We found that medicines were being not stored safely during medicines rounds and administration was not recorded correctly. We found that care plans for the management of medicines and creams did not contain sufficient detail to make sure that residents received appropriate care.

You can see what action we told the provider to take at the back of the full version of the report.

Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is over three floors and has four separate units and each unit had separate dining and communal areas. All bedrooms in the home are for single occupancy and have ensuite facilities. The service provides support to adults who have a physical disability, mental health needs, behaviour support needs, dementia and complex nursing needs. During the period of the inspection there were 67 people living there.

The service had a registered manager in post. 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.

We spoke with people in their own rooms and those who were sitting in the communal areas and were told by people that they felt the standard of care was satisfactory. The home had moving and handling equipment and aids to meet people’s mobility needs and to promote their independence. The home was being maintained and we found that all areas were clean and free from unpleasant odours.

We found that there was sufficient staff on duty to provide support to people to meet individual’s personal care needs. Staff had received training relevant to their roles and were supported and supervised by the registered manager and the care manager. The home had effective systems when new staff were recruited and all staff had appropriate security checks before starting work. The staff we spoke with were aware of their responsibilities to protect people from harm or abuse.

The service had worked well with health care professionals and external agencies such as social services and mental health services and the Care Home Education and Support Service to provide appropriate care to meet people’s different physical, psychological and emotional needs.

The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves.

People were able to see their friends and families as they wanted and go out into the community with support. There were no restrictions on when people could visit the home. All the visitors we spoke with told us that staff were “friendly”.

People had a choice of meals and drinks. People who needed support to eat and drink received this in a supportive and respectful manner. We saw that people were supported to maintain their independence and control over their lives as much as possible.

There were quality monitoring systems in place and being used to assess and review the quality of the services provided.

Inspection carried out on 11 May 2015

During an inspection to make sure that the improvements required had been made

We carried out an unannounced comprehensive inspection of this service on 21and 22 October 2015 at which breaches of legal requirements were found that had an impact on people living in the home. This was because the registered provider had not always made sure there was the right mixture of staff skills and experience on all shifts or that training and staff support was monitored so people could be sure staff had the right skills and experience to support them.

Following the comprehensive inspection , 21and 22 October, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. They sent us an action plan setting out what they would do to improve the service and meet the requirements in relation to the breaches and when this would be completed

After that inspection, 21and 22 October, we received concerns from other agencies and individuals in relation to the levels of suitably qualified staff being deployed in the home to meet people’s needs and to provide individual support where it was needed. As a result we undertook a focused inspection on 11 May 2015 to look into those concerns. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Heron Hill Care Home on our website at www.cqc.org.uk

Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is on three floors and has four separate units each with separate dining and communal areas. All bedrooms are single occupancy and have en suite facilities. The service provides support to adults who have a physical disability, mental health needs, behaviour support needs, dementia and complex nursing needs. At the time of our visit there were 66 people living in the home.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.

We found on the day of our visit, 11May 2015, that there was an adequate level of staff on duty to meet minimum requirements. However the evidence we saw indicated that this level of staffing was not always being maintained as nursing staff levels were not consistent across all units that required nursing support and leadership. This meant the levels of care support people received was inconsistent.

We also noted that one to one support provided to people assessed as needing this was not consistent either with different staffing arrangements on different units. This meant that some people might not get the level of individual support and supervision they had been assessed as needing.

We found that staff and the registered manager were working hard to try to maintain a safe service and to recruit and retain suitable staff. We could see that the use of agency staffing was decreasing and the registered manager anticipated that within a period of weeks there would no longer be a need to use agency support staff as new staff started.

You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 21 and 22 October 2014

During a routine inspection

This unannounced inspection took place over two days on 21 and 22 October 2014. During our previous inspection visits on 22 July, 9 August and 10 September 2014 we found the service was not meeting all the regulations we looked at. This was because the registered provider did not have appropriate arrangements in place to manage and monitor medicines safely, was not ensuring that the premises were being well maintained and that premises and equipment were kept clean and hygienic to reduce the risk of infection.

We took enforcement action and issued three warning notices to the provider that required them to make immediate improvements in relation to the way medicines were managed and monitored. The warning notices also required them to make improvements to the environment, equipment and infection control to protect people living at the home.

The registered provider wrote to us and gave us an action plan saying how and by what date they intended to improve the premises, infection control and the way medicines were managed. The registered provider also gave us a voluntary undertaking to take no further admissions whilst they addressed the breaches. At this inspection on 21 and 22 October 2014 we found that the registered provider had made the improvements needed to meet the requirements of the warning notices and compliance actions from the previous visits. However at this inspection we found that there were others breaches of regulations that had an impact on people living in the home.

Heron Hill Care Home provides accommodation and nursing care for up to 86 people. The home is on three floors and has four separate units each with separate dining and communal areas. All bedrooms are single occupancy and have ensuite facilities. The service provides support to adults who have a physical disability, mental health needs, behaviour support needs, dementia and complex nursing needs.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.

We found that there were adequate numbers of staff to provide support to people to meet basic care needs but the registered provider had not always made sure there was the right mixture of staff skills and experience on all shifts to meet assessed needs and behaviours. We also found that training and staff support was not being well monitored or recorded so people could be sure all staff had the right skills and experience to support them.

We found that records of what staff training had taken place and staff supervision were not up to date. We saw that staff working with people whose behaviour may challenge the service were not being enabled to access accredited training relevant to their workplace and role. This meant that people could not be sure that staff always had the right training to carry out their roles effectively.

There were limited organised activities provision available to people. We found that reductions in the activities staff meant that people were not regularly being given the opportunity to have support to follow their own interests and to take part in organised activities with others. This could affect their social inclusion.

The systems used to assess the quality of the service had not identified all the issues that we found during the inspection. Whilst we found that some aspects of the quality monitoring processes were being done well others, such as monitoring staff training.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to making sure staff always had the right skills, competencies and knowledge to meet the needs of people who used the service. The registered provider had not made sure that all staff in the home had received induction training, appropriate training for their roles or regular supervision and appraisal to monitor their performance. We also found that people were not being protected against the risk of unsafe care because the registered provider had not made sure that all aspects of service provision were being regularly monitored for effectiveness. You can see what action we told the provider to take at the back of the full version of this report.

We found that people living at Heron Hill Care Home were able to see their friends and families as they wanted. There were no restrictions on when people could visit them. We could see that people made day to day choices about their lives in the home and were able to follow their own faiths. People living there and visiting relatives told us that staff were polite and caring and “Worked very hard”.

The premises and equipment were being well maintained for the people living there. People’s needs had been assessed and care plans developed. There were suitable hoists and moving aids in use in the home to assist with the different mobility needs of people living there.

Staff had liaised with other healthcare professionals to make sure specialist advice was available to people for the care and treatment they needed. Medicines were being administered and recorded appropriately and were being kept safely.

Care records contained information about the way people would like to be cared for at the end of their lives. There was information which showed the provider had discussed with people if they wished to be resuscitated. The service had policies in place in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

The home had effective systems when new staff were recruited and all staff had appropriate security checks before starting work.

Inspection carried out on 10 September 2014

During an inspection in response to concerns

Our inspection team was made up of two inspectors. Below is a summary of what we found. The summary is based on our observations during the two visits, discussions with staff and looking at records.

We considered our inspection findings to answer the questions we always ask:

� Is the service safe?

� Is the service effective?

� Is the service caring?

� Is the service responsive?

� Is the service well-led?

This is a summary of what we found. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

Before our visit we received information that at times staff levels had been low so that staff might not have time to give appropriate and effective care to people. We made two unannounced out of hours visits to check on staff levels.

We saw there were adequate levels of nursing and care staff on duty at the times of our two visits. Agency staff were also working in the home to help ensure that an adequate level of care and nursing staff was maintained. At times the numbers of agency staff was high, especially on night duty. However the agency staff had been working in the home for some months and so had become more familiar with the service and people living there.

Is the service effective?

We found that the provider was actively recruiting staff to increase the number of permanent staff employed in the home. This would reduce the need to have agency staff.

Is the service caring?

From our observations during the two visits we saw that staff were respectful and gave encouragement and prompting when supporting people. For example we observed positive staff interactions with people taking their tablets, eating and having their drinks.

Is the service responsive?

We observed that a member of agency staff had been brought in to provide additional observation for a person who had injured their head. The staff were monitoring their condition.

We observed that night staff were predominately male. This meant that the choice for people to have only female carers at night, should they prefer that, was not possible.

Is the service well-led?

The staffing levels in the home had been reduced and at times low. In response to this the provider had put interim contingency actions in place. This included using agency staff in the short term to maintain better staffing levels, extra overtime shifts for permanent staff and an on going recruitment drive.

Inspection carried out on 22 July and 9 August 2014

During an inspection to make sure that the improvements required had been made

Our inspection team was made up of an inspector and a pharmacist. The inspection of outcome nine, medicines management was carried out by a pharmacist inspector.

Below is a summary of what we found. The summary is based on our observations during the inspections, discussions with staff, looking at supplies of medicines and looking at records.

During this inspection we checked if compliance actions we made at the last inspection in April 2014 had been completed. We also looked at outcomes in response to concerns raised with us that one or more of the essential standards of quality and safety were not being met.

We considered our inspection findings to answer the questions we always ask:

� is the service safe?

� Is the service effective?

� Is the service caring?

� Is the service responsive?

� Is the service well-led?

This is a summary of what we found. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We looked at the records of two applications that had been made. These had been correctly submitted and were in order. The service had appropriate policies and procedures in place in relation to this and also regarding the Mental Capacity Act 2005.

At our visit in April 2014 we found that the provider did not have a robust recruitment procedure in practice. The recruitment records we viewed during this inspection had all of the information required to show that a variety of checks of suitability had been completed. This would help to ensure that people being employed were of good character, physically and mentally fit for the work and had the right qualifications or skills and experience.

Before our visit we received information that at times staff levels had been low so that staff might not have time to give appropriate and effective care to people. We made two visits to check on staff levels. There were adequate levels of nursing and care staff on duty at the visits. Agency staff were working in the home because the provider had identified there was a shortage of care and nursing staff. We asked the manager to provide us with information on the staff establishment, the rotas, staff levels, deployment and recruitment updates on a two weekly basis. This was to monitor the interim staffing arrangements in place.

We found that the service was not safe because people were not protected against the risks associated with use and management of medicines. People did not always receive their medicines in a safe way. Medicines were not administered and recorded appropriately.

We found that maintenance and redecoration work that we had been told would be taking place had still not been attended to in the communal areas and corridors of the home. This meant that people living at Heron Hill did not have a well maintained, home that was easy to keep clean and hygienic. Communal areas and the lounge furnishings did not provide pleasant environments to spend time in.

Equipment in the home was being maintained under service contracts. The records of how or when the items had been cleaned and visually checked by staff were not up to date or present in some cases. We could see that there were various marks and discoloration, accumulations of dust and some staining on the hoists, bath aids, wheelchairs and sitting weighing machines we examined. This indicated that equipment was not being cleaned and checked to make sure it was clean and ready to use.

Is the service effective?

We found that care plans for managing medicines were poor and staff did not have clear guidance available to them to make sure that people received appropriate care.

Visitors we spoke with confirmed that they could visit anytime. They also told us they could see their relatives in private in their rooms as well as communal areas.

We found that mobility equipment was in place and people had been assessed for its use. The equipment and how it was to be used was set out in people�s care plans.

During our inspection it became evident that the systems being used to monitor the quality of the services provided were not being effective. We found that the system of checks or 'audits' being used by the service as part of their quality monitoring were not always robust and fully effective. For example, environmental defects had not been acted upon and medicines practices were not being effectively monitored.

Is the service caring?

We observed that staff were respectful and gave encouragement and prompting when supporting people, for example with meals and drinks.

People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

Relatives told us the staff �Come very quickly when he needs them�. We were also told that the staff had been �Brilliant� with their relative.

Is the service responsive?

Relatives we spoke with told us that staff listened to them and kept them informed of any changes in their relative�s needs. We were also told that, �If we have raised anything we were not happy with we have had no problems getting it done�.

People living there were able to join in organised activities if they wanted to and some people went out into the local community. We saw people were able to follow their own faiths and attend religious services if they wanted to. There was a multi denominational religious service on the day we visited. We saw staff asking people if they wanted to attend the service.

Records confirmed people's preferences, interests and different needs had been recorded and care and support had been provided that met their wishes.

Is the service well-led?

At our visit in April 2014 we found that the provider did not have a robust recruitment procedure in practice. At this inspection the provider had made the improvements they stated in their action plan. The records we viewed had all of the information required by regulation. This meant that the provider had improved the systems in operation to help make sure people being employed were fit for the work and had the right qualifications and skills.

The staffing levels in the home had been affected by shortages, staff sickness, suspensions and leave. In response to this the provider had put interim contingency actions in place. This included using agency staff in the short term to maintain better staffing.

Quality assurance processes were in place. We saw that audits, or checks of medicines, were done to assess the way medicines were managed. However, we had concerns about the way medicines were handled and these were not identified or managed appropriately through the audits. Monitoring of equipment cleaning and visual checks had also not been effectively monitored.

On our inspection of 12 November 2013 we made a compliance action requiring them to be compliant with the provisions of the regulation for the safety and suitability of premises. We were given timescales for this work to start. These timescales had not been kept by the provider to protect people from the risks associated with unsuitable and unhygienic environments.

Inspection carried out on 8, 15 April 2014

During a routine inspection

The inspection team who carried out this inspection consisted of two inspectors, a pharmacist and an expert by experience. During the inspection, the team worked together to answer five key questions, is the service safe, effective, caring, responsive and well led?

Below is a summary of what we found. The summary is based upon our observations, discussions with people who used the service, their relatives and the staff who supported them and from looking at the records held in the home. We also observed the interactions between people living there and the staff supporting and caring for them.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

At a previous inspection we found people were not being protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage them. We found that improvements had been made to medication management. We saw that appropriate arrangements were in place in relation to the management and recording of medicines to help ensure they were given safely.

There were enough staff on duty to meet the needs of the people who lived at the home and we saw they had received training appropriate to their role. The provider had contingency plans in place for dealing with foreseeable emergencies including staffing.

Recruitment records for staff who had recently been employed did not contain all the information required by the Health and Social Care Act 2008. This meant the provider could not demonstrate that the staff recently employed to work at the home were suitable and of good character to support the people living in the home. A compliance action has been set for this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes and we saw that proper policies and procedures were in place.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. People spoke well of the staff caring for them and said that they felt staff listened to what they had to say and did as they asked.

We saw in care plans that people's health and care needs had been assessed with them and/or their families and that this was reviewed regularly. Risks to their health and wellbeing had been assessed and plans put in place to manage them.

Specialist dietary, mobility and equipment needs had been identified in care plans and action had been taken to meet them. We found that the provider had procedures in place for obtaining valid consent and what people’s wishes were if their health deteriorated. However evidence of who held legal authority for a person under power of attorney was not evident in practice within people's care files. This meant that staff did not have prompt access to this information.

People's different needs were taken into account with the layout of the home and the signage used to promote their understanding and independence. A major refurbishment programme was being implemented to improve the environment for the people living there. We saw confirmation of this.

People who live there and relatives we spoke with confirmed there were a range of activities for people to take part in. Relatives told us the staff made them welcome and kept them informed about any changes in their relative’s needs.

Is the service caring?

People we saw in the home were supported by suitably trained and supportive staff. We saw that care workers gave encouragement when supporting people and gave people the time to respond. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

From our observations and what people told us we found that people's preferences, personal interests and wishes were discussed with them and recorded. We were told staff were "kind” and “reassuring”. One person told us that, “When I arrived they told me I would be alright”. We observed that staff interacted with people in a positive way.

Is the service responsive?

People's needs had been appropriately assessed before they moved into the home. People told us they had key workers and also about the 'service user of the day' that focused upon a different person each day. It also helped to make sure that all care files, and risk assessments were reviewed.

Records confirmed people's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided that met their wishes. We found that the manager monitored complaints and had responded under the home’s procedures.

Is the service well-led?

Quality assurance processes were in place and people told us they were asked for their feedback on the service they received. This was through satisfaction surveys and via regular home meetings.

The staff told us that the management team was supportive and held regular meetings to promote good communication. Staff told us they were supported by the management team and had been given opportunities to train and develop professionally.

The service kept records of all accidents and incidents that had occurred in the home and also of notifications required by regulation to CQC. The service worked well with other key organisations, including the community mental health team, the local authority and safeguarding teams. This approach helped to support care provision and service development.

Inspection carried out on 26 November 2013

During an inspection in response to concerns

We spoke with two people who were very complimentary about staff. One person had no concerns about their medication and said that they always got their medicines on time.

Whilst people who we spoke with were happy with the care they received we saw that medicines were not always managed properly. In particular we saw records for creams and care plans relating to medication that were inadequate and did not show that appropriate care was provided.

Inspection carried out on 12 November 2013

During a routine inspection

People who lived at Heron Hill and their relatives we spoke with expressed satisfaction with the service provided. We were told, "I have no issues" and "I like it here". A relative told us, "I've never had any issues about the staff". There were sufficient numbers of staff with different skills to support the people living in the home.

We saw that staff treated people with dignity and respect and support was provided in a warm and friendly manner. We saw that people were able to join in meaningful and sociable activities if they wished.

Staff liaised with other healthcare professionals and organisations to ensure timely and appropriate treatment was provided for people. The provider had effective recruitment procedures in place and had carried out relevant checks on the staff they employed. This helped to make sure that staff were suitable for working with the people living there. Staff levels were subject to review.

We found that the physical environment of the home was safe but repairs had not always been carried out immediately as there was not a regular scheme of renewal and refurbishment in place. The furniture and fittings were worn and there were areas of damage that affected hygeine and did not promote wellbeing.

We found that each person living in the home had a plan of care where their assessed needs and preferences were stated. Some records were not clear, and complete or updated promptly. Nutritional screening was in use to help protect people.

Inspection carried out on 10 December 2012

During a routine inspection

People who were able to speak with us said that they had not felt the need to complain about their care and they all felt the staff would help them if something bothered them. We had evidence to show that complaints were managed appropriately. People told us they liked the staff who worked there. One person told us that "Everything's fine." The home had systems in place to protect people from abuse and to promote their rights. Staff had received training in how to recognise abuse and on how to deal with any concerns. We found that there were enough staff to meet people's needs and that the home had systems in place for monitoring the quality and standard of the service it delivered.

We spent a lot of time observing daily life in the home and at the lunch time meal and saw that there were staff available to help people with their meals and prompt them to eat and drink. Some people in the home had limited verbal communication, therefore we spent time observing people's behaviour and their interactions with staff. We did not observe any negative interactions between staff and people in the home. We also observed staff responding to people who needed help at meal times. People told us the food was "good" and told us that they were always given a choice and asked what they liked and wanted. We saw the food choices on the menu board.

On our walk around the building we saw that people had been able to personalise their rooms with their own pictures and personal items.