Heartlands

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement.
At this assessment the rating has changed to good
This meant people were safe and protected from avoidable harm.
The service was no longer in breach of legal regulation in relation to safe care and treatment. Which meant concerns relating to the safety of the care environment and the way people’s medicines were managed had improved.
 

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based openness and honesty staff listened to concerns about safety and investigated and reported safety events. lessons were learnt to continually identify and embed good practice.
At this inspection, we found the provider had made and embedded significant improvements in learning from incidents and accidents, strengthening the service’s learning culture and improving safety outcomes for people.
The provider now takes a proactive approach to safety using audits and monitoring. For example, call bell response time checks were carried out to identify issues and drive improvements in response times. The registered manager reviewed performance regularly, resulting in steady and measurable improvements in care practice and care recording.
The management team shared learning through staff meetings, supervisions, and ongoing communication. Staff reflected on incidents and applied learning in practice more consistently. The provider reviewed care plans and risk assessments following incidents and make appropriate referrals to healthcare professionals where needed.
Overall, the service demonstrates a more effective and embedded learning culture that supports safer care.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Prior to care being delivered, people new to the service received a comprehensive pre-admission assessment to determine whether people’s needs could be safely met. The registered manager reviewed all new admissions, ensuring processes were consistently followed and transitions into the service were well planned and managed.

The provider strengthened these processes further by introducing a new checklist and sign-off procedure for all new admissions, with a particular focus on dietary requirements. Individual IDDSI profiles are now completed for each person and must be completed prior to admission. These were formally reviewed and signed off by both the registered manager and the chef, ensuring all dietary needs are clearly understood and safely managed from the point of admission. This is also recorded and maintained on the electronic care system and ring binders on each floor to ensure staff have consistent access to up-to-date guidance.

The provider involved people and their relatives in the development of care plans from the point of admission, supporting continuity of care and ensuring individual preferences and needs were reflected from the outset. Staff supported people to attend external healthcare appointments and worked with relatives to ensure appropriate arrangements were in place. Where healthcare professionals provided advice, staff updated care records promptly to ensure care remained accurate and responsive.

Overall, systems and processes supported safe, coordinated, and person-centred transitions into the service, with strengthened oversight of dietary needs contributing to improved safety outcomes.
 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.
Staff followed a clear safeguarding policy and had received appropriate safeguarding training. They understood how to recognise, and report concerns and acted promptly when they suspected abuse. Staff followed escalation processes, including reporting to the local authority where required. They also recognised signs of emotional distress and responded appropriately to support people.
People said they felt safe living at the service and knew how to raise concerns. The provider reported safeguarding concerns promptly to the local authority and submitted notifications to CQC in line with requirements.
Relatives expressed confidence in the safety of the service. One relative told us “my loved one would tell me if my loved one felt unsafe my loved one has a mobile phone to call me I have no concerns.”
When incidents occurred, staff took immediate action to reduce risk, including introducing appropriate equipment and monitoring systems. Overall, staff consistently followed safeguarding procedures and supported people to feel safe.
We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that when needed, DoLS applications and authorisations were in place for people. Care records contained information to inform staff if a person had a DoLS in place.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA).
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
At the last inspection we found the provider’s procedures for assessing, monitoring and mitigating risks within the care environment, increased the risk of harm to people who used the service. We found concerns in relation to aspects of fire safety; controlled access to high-risk areas; infection prevention and control standards; waste disposal and the effectiveness of maintenance procedures at the service. We also found risks associated with the management of people’s medicines were not always safely managed.
At this inspection we found significant improvements had been made. The provider actively involved people, and where appropriate their relatives, in reviewing and managing risks. Staff worked with people to develop and update care plans, ensuring these reflected individual preferences and supported safe care delivery. This approach ensured people remained involved in decisions about their care and how risks were managed.
Staff understood people’s individual risks and followed care plans. They accessed up-to-date care records and risk assessments through the electronic care system, using handheld devices to review information and respond promptly to any changes.
Staff supported people with complex needs, including those living with dementia, by following detailed care plans. These plans identified triggers for distress and provided clear guidance on how to respond and de-escalate situations safely. Staff implemented control measures effectively to reduce risks, including for people at risk of self-harm.
Care plans included clear guidance on managing risks such as falls, catheter care, skin integrity, and diabetes. Staff used this information to provide safe and consistent care.
The provider organised staffing to support risk management, allocating staff to specific areas of the home during each shift. This ensured staff supervised communal areas and responded quickly to people’s needs, helping to reduce risks and maintain people’s safety.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

At the previous inspection, people were not always cared for in a safe and well-maintained environment. Concerns were identified in relation to fire safety, access to Staff only secured areas infection prevention and control, waste management, and the effectiveness of maintenance systems.
At this inspection, we found the provider had taken action to address all identified concerns, and improvements had been embedded into practice. The provider introduced strengthened systems and processes, including regular environmental audits and safety checks carried out by both the management team and regional management team, to ensure ongoing oversight and compliance.
The provider ensured fire safety systems were effective, including the maintenance and functioning of fire doors. Fire safety equipment was regularly tested, and the provider introduced quarterly evacuation simulations to strengthen preparedness.
Access to staff only secured areas was now appropriately controlled, with secure systems in place and no visible access codes compromising safety. Infection prevention and control standards and waste management processes had improved, supporting a safer environment for people and staff.
The provider also addressed environmental risks, such as trip hazards, ensuring communal areas were free from trailing wires and hazards. Maintenance systems had improved, with clearer processes for reporting, tracking, and completing repairs in a timely way. The provider introduced improved oversight of maintenance requests to ensure issues were followed up and resolved promptly.
The environment continued to meet people’s needs, including access to safe outdoor spaces. Personal emergency evacuation plans (PEEPs) were in place for all people and regularly reviewed. The provider maintained an up-to-date emergency evacuation plan and ensured staff were trained in how to respond.
Overall, the provider demonstrated that previous environmental and safety concerns had been addressed, with improved systems, oversight, and ongoing monitoring ensuring a safe, well-maintained environment for people.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.
The provider followed safe recruitment processes, including references and enhanced DBS checks to ensure staff suitability. Staff completed an induction programme, which included training and shadowing experienced colleagues to understand people’s needs.
The provider ensured staff received ongoing training and support. We found that staff had completed regular refresher training and spoke positively about the mix of online and face-to-face learning.
We noticed gaps in staff supervision records; however, staff we spoke to were happy with the supervision they received and felt able to approach managers at any time for concerns or developmental opportunities.
The provider used a dependency tool to help calculate staffing numbers.one staff member told us “I think staffing levels are good to be honest. They are always adjusted by the manager if people’s needs change, the manager is very particular about this.” At the time of this inspection the service was overstaffed according to the calculations. We found there were enough staff to safely meet people’s needs. Staff were available to support people in a timely way; call bells were being answered and staff had time to sit with people.
Staff worked well as a team and supported newer colleagues. While some staff and relatives felt additional staff would be helpful during busy periods, others said staff were available when needed.
Staff supported people appropriately, including during mealtimes, and demonstrated a clear understanding of their roles. People appeared relaxed and comfortable with staff. Overall, staffing arrangements supported safe and effective care delivery.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.
At the previous inspection, the provider did not always maintain safe infection prevention and control standards. Issues included poor hygiene, unsafe storage of clinical waste, and poor maintenance that increased the risk of infection.
At this inspection, we found the provider had taken prompt and appropriate action to address these concerns, improvements had been embedded and sustained in practice. The provider ensured all areas were clean, well-maintained, and suitable for use. Areas previously identified as unsuitable had been repaired or replaced, including kitchenettes which had been fully replaced, improving hygiene standards and enabling effective cleaning.
Clinical waste was now stored and disposed of safely, with secure systems in place to prevent unauthorised access.
The provider strengthened oversight through regular infection prevention and control audits and environmental checks, ensuring issues were identified and addressed promptly. Cleaning schedules were consistently followed, and housekeeping staff maintained a clean environment throughout the service.
Staff received infection prevention and control training and understood how and when to use personal protective equipment PPE. PPE was readily available, and staff used it appropriately.
People and their relatives expressed confidence in the cleanliness of the service, and we observed that the environment was clean, tidy, and well-managed.
Overall, the provider demonstrated that previous risks had been effectively addressed, with sustained improvements supporting a safe and hygienic environment for people.
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.
We found medicines management had improved, with the provider taking effective action to address previous concerns. At this inspection, we found that all required actions had been met, and improvements to systems, practice, and oversight had been embedded and sustained.
The provider strengthened medicines governance by improving documentation, audit processes, and staff practice. Systems now ensure that medicines, including covert medicines, are managed safely and in line with best practice guidance. The provider obtained appropriate authorisation and guidance from healthcare professionals, and ensured clear records were in place to support safe administration.
The provider reviewed emergency medicines arrangements and introduced clear protocols to ensure timely access and safe administration. Staff now understand emergency procedures, and the provider maintains appropriate stock levels in line with care plans to reduce risks.
The provider had improved the management and auditing of controlled drugs. Records were accurate, regularly reviewed, and effectively monitored to ensure accountability and safe handling of high-risk medicines.
The management team strengthened audit systems, resulting in improved oversight and timely identification of any issues. Staff received additional training and competency checks, supporting safe and consistent practice.
People and their relatives did not raise concerns about medicines management and felt confident that medicines were administered appropriately.
Overall, the provider addressed previous risks, improved systems and documentation, and embedded robust processes to ensure medicines are managed safely and effectively.