Heaton House Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

During our assessment of this key question we found the provider’s governance systems were not always effective, did not drive improvement and did not identify all of the shortfalls we found during this assessment. We found limited improvements had been made by the provider to ensure records were completed contemporaneously and systems implemented which monitored, assessed and managed the quality of service provision. This has resulted in a breach of regulation relating to good governance. You can find more details of our concerns in the evidence category findings below. We found the deputy manager was responsible for the day to day running of the home; they told us they were responsible for making all the decisions and doing audits. The majority of staff felt the home was well-led, however, this was as a result of the deputy manager’s involvement. At the previous inspection we raised concerns about the management model and how the registered manager was unaware of issues we had identified, due to not being ‘hands on’ with managing the home. At this on-site assessment visit, when we provided feedback, the registered manager was again unaware of the gaps and issues we had identified. None of the audits we saw had been completed by the registered manager. The provider had not ensured staff received the appropriate training to enable them to support people safely. Care plans did not contain all the necessary information ensure people's needs were safely met and some people's risk assessments were missing.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager of Heaton House is also the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. However, they were not responsible for the day to day running of the home, which was the responsibility of the deputy manager, who told us they had no previous experience of managing a residential care home. The deputy manager told us: “Day to day I am running things, I make most of the decisions, I am responsible for audits, supervisions, hands on work with professionals, support the seniors etc. The registered manager's involvement is mainly paying for things, having the final say for things, he is here most days.” The majority of staff felt the home was well-led, albeit this was because of the deputy manager’s involvement. One staff member told us, “Yeah, [the home is well-led] but could be a bit stricter; getting there with it. [Deputy manager name] runs the home.”

We found processes in place did not ensure leaders at every level were visible, leading by example and modelling inclusive behaviours. The registered manager was unaware of the issues we identified during the on-site assessment visit, due to them not being ‘hands on’ with managing the home. The provider questioned the deputy manager about what was being done to rectify these issues. None of the audits we saw had been completed by the registered manager. When we provided feedback at the end of our site visit, the registered manager was again unaware of the gaps and issues we had identified. The registered manager told us they would look at increasing the responsibilities of the senior carers, so they had more involvement in audits and monitoring. We discussed the role of the registered manager/nominated individual, and how, rather than repeatedly delegating tasks downwards, which had not been successful to date, the provider needed to consider taking a more active role in providing oversight of the home, and in supporting the deputy manager.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

During this assessment site visit we found limited improvement had been made and the provider was unable to demonstrate how they had acted upon and rectified the breaches of regulation we had previously identified in June 2023. The deputy manager told us when they had started work at the home, there was no real audit system or processes in place, so they had started to implement one, which was a work in progress, with the creating and revising of audits. The deputy manager also confirmed there was no current audit schedule in place, although the plan was for all audits to be done each month. The deputy manager also stated he could not provide a consistent set of completed audits which dated from the previous inspection to the current day; they also stated the home did not have, or use an overarching action and improvement plan, although one was being created, which would be shared with the registered manager, so they knew what was being worked on. The deputy manager told us, "There are various audits which have been completed, but these are not consistent. Some [audits]were not suitable, so I am redesigning these. We don’t have an overarching action plan currently, but this is being created. This will then be sent to [registered manager and finance director names].

There was a lack of clear responsibilities, roles, systems of accountability and good governance, which should have been in place to manage and deliver good quality, sustainable care and support. As there was no overarching action plan in place, the provider did not have oversight of shortfalls within the home, and what improvements were required. We saw evidence some auditing and monitoring had been done, however, where any actions had been identified, no updates had been recorded to explain if these had been addressed. We also noted examples were issues and concerns had 'rolled over' from one month to the next, which demonstrated improvements were not being made in a timely way. For example, a building infection control audit dated 29 October 2023 indicated flushing of infrequently used outlets was not being done; the same audit dated 30 January 2024 stated flushing was still not being done. An equipment audit dated October 2023 identified new slings were required; the same audit in November 2023 stated new slings were required. The deputy manager told us the home still only has 1 sling and the use of the hoist was not required by any person at the time of our site visit. A mattress audit had identified mattresses covers were ripped or needed cleaning, however there was no record this work had been done. A kitchen audit dated 7 February 2024 had identified issues with paperwork not being completed correctly, food not labelled correctly, and food temperatures not documented consistently; the provider was unaware of this, as no previous auditing of kitchen records had been completed and there was no action plan provided to us to explain how this was being addressed.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We spoke with the registered manager who expressed concerns about the number of inspections or assessments which CQC had completed over the previous 2 years, and how they felt CQC did not allow enough time for improvement to be made between visits. The registered manager also commented on how despite addressing concerns between inspections, CQC had identified new issues and classed these as a continued breach, which they did not think was fair. We explained how CQC assesses and inspects against regulations. The registered manager also spoke about a recent CQC registration manager visit, linked to a provider application to increase bed capacity at the home. The visit by the CQC registration manager had identified a number of significant concerns about the environment and fire safety, which we shared with the fire service authority. The registered manager told us the rooms had met building regulations, only for CQC to say they did not meet registration regulations, and had not expected CQC to have separate regulations and requirements, which differed to building regulations, despite this being expected of a registered person.

We reviewed accident, incident and safeguarding records; these indicated statutory notifications had not been submitted to CQC as required. For example, in November 2023, a vulnerable person who lacked capacity was able to leave the premises as the front door had been left open, whilst work was being carried out and a safeguarding alert was raised with the local authority; the log stated the director would notify CQC of this, but there was no notification found on our system. We found 3 other examples where people had fallen but CQC had not been notified. The provider's business continuity plan stated alternative accommodation had been identified in case of emergency; this was Ashcroft Housing Association, Heaton, Rochdale, some 1 minutes walking distance. This clearly related to the provider's other care home, and not Heaton House, and was discussed during our assessment site visit; no place of safety or alternative accommodation had been sought. As a result, if any major issues affected the home, for example, complete power loss or heating failure, there was no active plan in place to ensure the wellbeing and continued support of people. The local authority had identified, through their own monitoring processes, policies hadn’t been reviewed, there were no logs in place to support management in monitoring and reviewing DoLS, incidents, accident, complaints, and safeguarding; this reflected our findings. There was no evidence to identify continuous learning to improve the quality of life for people. The registered manager did not have a good understanding of how to make improvements happen. There were no processes to ensure learning happened when things had gone wrong, and from examples of good practice. The registered manager did not encourage reflection and collective problem-solving.