You are here

Heathcotes Grove House Inadequate

Inspection Summary

Overall summary & rating


Updated 26 August 2020

About the service

Heathcotes Grove House is a large detached house near the town centre. It is registered for the support of up to eight adults and children of 16 years and over. Support is provided for people with learning disabilities and other complex needs. One person was using the service at the time of our inspection.

The service is bigger than most domestic style properties and is larger than current best practice guidance. However, the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

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

Systems in place had not always protected people from abuse. People had not been asked if they felt safe or what they could do if they worried or concerned. A relative told us they did not feel their family member was always safe at the service. Staff told us they had not felt safe when incidents happened at the service.

The provider had not always dealt with incidents appropriately to minimise people’s risks. Some restrictive practices had been in use that were not in line with current legislation and national guidance and staff had not received training in this area.

People were not always helped to communicate their needs. Although guidance had been given to staff about ways to communicate with people, information was not always available to people in a format they could understand.

Risk assessments in place were detailed and person centred. However, people’s individual risks related to COVID-19 had not been identified. Medicines were not always managed safely. Medicine records were poor and this meant it was hard to tell what medicines people had received. During our inspection we found the provider had identified issues with people’s medicine records and had started to make changes to put things right.

Staff did not follow safe infection prevention and control practices or follow up to date COVID-19 guidance to help stop the spread of infection.

Staffing numbers were adequate but new staff were covering shifts, without adequate training. There were periods where no senior leadership was in place and staff rostered to work did not always have the skills and knowledge they needed to support people. This meant people were at risk of unsafe care and treatment.

Governance arrangements at the service were not sufficient or robust enough to monitor and assess the quality and safety of the service or the welfare of people. Staff did not receive effective support from the management team to keep people safe. The lack of robust management meant there was no consistent oversight of the service.

The quality of care people received had deteriorated since our last inspection. The provider failed to act on all of the concerns we raised previously or to learn lessons when things went wrong. Where improvements had been made, they were not adequately embedded within the culture of the service.

Rating at last inspection

The last rating for this service was requires improvement (published 28 January 2020).

Why we inspected

We received concerns in relation to the reporting of incidents and how these were acted upon, infection control procedures and risk management, medicine management and lack of staff training and skill mix. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating a

Inspection areas



Updated 26 August 2020

The service was not safe.

Details are in our safe findings below.



Updated 28 January 2020

The service was effective.

Details are in our effective findings below.



Updated 28 January 2020

The service was caring.

Details are in our caring findings below.



Updated 28 January 2020

The service was responsive.

Details are in our responsive findings below.



Updated 26 August 2020

The service was not well-led.

Details are in our well-led findings below.