Heaton House

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

The home had a well‑established and proactive culture of safety, supported by clear processes and an open, transparent approach to incident management. Staff understood their safeguarding responsibilities and demonstrated compliance with statutory requirements, including Duty of Candour. Children were safeguarded through robust risk management arrangements, including individual assessments, timely health checks, and ongoing monitoring of the care environment. Staff were trained to the appropriate safeguarding and restraint‑reduction standards, ensuring they were equipped to recognise and respond to risks effectively.

Mostly, effective systems supported safe record‑keeping, collaborative working, and coordinated care. Transition planning was strong and child‑centred.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The provider had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Incidents and complaints were appropriately investigated and reported. Any incidents were reported through the Care Incident Reporting Tool to help ensure robust oversight of incidents and effective identification of learning.

A monthly nursing report provided an oversight of incidents, with analysis of incidents to identify risks. There was evidence of clear lines of communication between the home and senior leaders to identify any wider learning. Learning from incidents and complaints was a standard agenda item in the monthly team meeting where learning was shared. For example, where there have been weaknesses in the timely receipt of incident forms, clear improvement actions have been identified to strengthen the process to improve early identification of learning to help protect children and staff from the risk of harm

Staff we spoke with understood their responsibilities to raise safety concerns and their responsibilities relating to Duty of Candour legislation. The aim of the Duty of Candour regulation is to ensure providers are open and transparent with people who use services and inform and apologise to them when things go wrong with their care and treatment.

The provider worked with children 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 children moved between different services.

Children’s health records were contemporary, comprehensive, and accurately reflected children’s needs, treatment plans, and consent decisions. Children’s records were securely stored in line with the provider’s Archiving, Disposal and Storage of Records policy.

Children’s transitions into and out of the home were well planned and effectively managed. Before admission, health practitioners worked closely with community and acute health services to develop a clear understanding of each child’s needs, strengths and care plans. Where possible, psychological formulations and positive behaviour support assessments were completed in advance, helping children to settle quickly and feel safe.

When children move on, transitions were carefully coordinated through planned visits, meetings and comprehensive information sharing with receiving professionals. This ensured continuity of care, reduced anxiety and supported positive outcomes for children during periods of change.

The provider worked well with children and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. Staff had a clear focus on improving children’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider always shared concerns quickly and appropriately.

There was a safeguarding policy in place and practitioners were familiar with the policy. The provider had a dedicated safeguarding team that had oversight of all safeguarding concerns and referrals. Care and Health practitioners were up-to-date with annual safeguarding training and were confident in raising safeguarding concerns. Some children in the home felt safe and knew who to talk to if they are worried or something makes them feel unsafe.

Safeguarding allegations raised by children, and concerns relating to staff conduct, were taken seriously and were fully investigated. The Local Authority Designated Officer (LADO) and the child’s social worker were informed promptly, and strategy discussions convened. Protective action was taken immediately when necessary, including removing staff from duties and making referrals to the Disclosure and Barring Service. Children were supported throughout the process and provided with appropriate feedback on the outcomes of investigations.

Staff were knowledgeable about the Deprivation of Liberty Safeguards (DoLS) under the Mental Capacity Act 2005 and worked to ensure that children were cared for in ways that did not unnecessarily restrict their freedom. Clear policies and procedures were in place for both restraint and DoLS.

The provider always worked well with children to fully understand and manage risks by thinking holistically. Staff provided care that fully met children’s needs and was safe, supportive and enabled children to do the things that mattered to them.

Risk assessments were regularly reviewed and updated by the mental health nurse, ensuring they remained current and responsive to the child’s presenting needs. The risk assessments and associated management plans we reviewed were comprehensive, detailed, and well‑structured. The management plan effectively outlined the child’s known triggers, early warning signs, and agreed de‑escalation strategies. Children were actively involved in their care and risk management planning, however families and partners we spoke to had inconsistent input and oversight of these plans.

There was a clear and proactive plan in place to reduce the risk of harm to the child or others. The documentation demonstrated a sensitive, child‑centred, and thorough understanding of the child, supporting staff to respond consistently and therapeutically to promote safety and wellbeing.

A review of staff records showed that all staff had completed training in line with the Restraint Reduction Network’s Training Standards. Several healthcare staff were accredited trainers for the Prevention and Management of Violence and Aggression (PMVA) training and delivered this in-house. Where restraint had been used to prevent self‑harm, incident reports and collaborative debriefs were completed. There was evidence that children had received a physical health check following any restraint incident, along with additional monitoring to reduce the risk of further harm.

The judgement for Safe environments is based on the latest evidence we assessed for the Safe key question.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met children’s individual needs.

The home benefited from a stable and well‑resourced healthcare team. Health professionals worked collaboratively to deliver care plans effectively and meet children’s individual health and wellbeing needs. A recent service re‑organisation has strengthened continuity of care, with mental health practitioners now allocated to the home. This has resulted in increased stability and consistency within the healthcare provision, including regular input from occupational therapy and psychology.

Healthcare staff received regular supervision which supported health practitioners to seek advice, escalate concerns and raise any emerging safeguarding issues.

Monthly team days provided an opportunity to share learning, receive peer training from healthcare practitioners and provide updates on children's psychological formulations. These are collaborative, information summaries to explain what might be behind a child's behaviour, distress, or mental health struggles.

Training records showed that all staff were up to date with mandatory training, ensuring they had the knowledge and skills required to deliver safe, effective care and to understand the needs of the children they supported. Training included medicines administration, infection prevention control and Prevention and Management of Violence and Aggression (PMVA) training. Staff received training on supporting people with a learning disability and autistic people.

The provider assessed and managed the risk of infection. They identified and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

Staff responsible for administering medicines followed correct infection prevention and control (IPC) procedures, and health staff had completed annual IPC e‑learning. Regular infection control audits were undertaken by a designated member of the care team with responsibility for health and safety. The outcome of the audits was discussed at monthly team meetings to share any learning or improvement in standards required.

Personal protective equipment and appropriate handwashing facilities were readily available and we observed staff adhering to their use.

There were policies and procedures available to support staff in the prevention and control of infections. The infection control policy had also been recently reviewed with staff as part of a team training day to raise awareness.

The provider made sure that medicines and treatments were safe and met children’s needs, capacities and preferences. Staff involved children in planning, including when changes happened.

Children received the medications they needed to manage their physical and mental health conditions. Medicines were prescribed, ordered and stored correctly and in line with national guidance. Children's medicines were reviewed regularly by in-house specialist doctors. Medicine administration was overseen by the nurse, and children were given easy-access information to help them understand the purpose of the medications they take to manage their conditions. Medicines administration was appropriately delegated to care staff who had the appropriate training and supervision. Staff knew how to record any medication errors, and this information was shared in a timely way with the nurse.

The home was supported by a pharmacist for clinical advice and stock management, which helped ensure that children’s medicines were prescribed, supplied, and administered in accordance with legislation and best practice.

Weekly medication audits were completed by home care staff and a monthly audit by the nurse. Audit reports were reviewed by the senior leadership team and themes analysis identified any learning and areas for improvement. However, on reviewing the medication audits for the previous 3 months we found weekly medication audits did not accurately record the numbers of medication errors. Strengthening of the accuracy of weekly audits and management oversight is needed to ensure that staff and leaders have an accurate understanding of medication errors in a timely way Accurate audit of medication errors for all audits undertaken is important to prevent future recurrences and reduce the risk of harm. Since the inspection, the provider has taken steps to strengthen the audit process. However, we have not assessed the impact of these improvements, as they were implemented after the inspection.