Heaton House Care Home

On this page

• 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

The provider was in the process of introducing a new audit and governance process. The new system was not fully embedded, and it was not clear what audits would be completed and how often. Recent audits completed had not identified some of the issues we found during our assessment. The provider had an overarching action plan, used to monitor and drive improvements. However, we noted the issues contained within this document had either been identified by us, or the consultancy firm, rather than through the provider’s own governance processes. There had been ongoing changes to the management team since the last assessment. Both the previous deputy manager and the recently appointed home manager had left, and the current deputy manager was running the home. People, relatives and staff spoke positively about this person, who was reported to be a visible presence in the home and willing to listen and help.

This service scored 54 (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.

Following the last assessment, the provider had informed CQC changes had been made to the management structure. A new home manager had been appointed, along with a new deputy manager, both of whom would oversee the running of the home. However, when we commenced this assessment, we found the home manager was no longer working at the home. Whilst a replacement was being sought, the deputy manager was overseeing the running of the home supported by a director.

People and relatives knew who the deputy manager was and said they were a visible presence in the home. Comments included, “They seem pleasant enough and are moving things along,” and, “Yes, I know them [deputy manager], if you want them, they come and talk to you.” Staff confirmed these views. One told us, “[Deputy Manager] is friendly, they walk around all the time, so we see them a lot. They listen to what we have to say and will get involved with care when needed.” People and relatives also commented on noting some improvements since the managerial changes had taken place. One relative stated, “I would say there are some improvements, such as menus on the table. The decoration in some areas has improved, and the quality of the new staff and the older staff that remained is much better.”

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.

At our previous assessment in March 2024, a new audit and governance process was being introduced. As a result, only a limited number of audits had been completed. At this assessment, we noted the audit and governance process had been changed again. The new system was not fully embedded, and it was not clear what audits would be completed and the frequency of each. We looked at governance processes completed to date and found between July and August 2024, only 4 audits had been completed. These covered the following areas; care plans, people’s weight, health and safety and use of the call bell. However, in September 2024, 11 audits had been completed, across a wider range of areas, including recruitment, mental capacity act, meal time experience, nutrition, infection prevention and control and safeguarding. Each area audited was given a score out of 100 to indicate how ‘compliant’ it was. From reviewing these completed audits, we found the process was not wholly robust. For example, the complaints audit had been scored at 100% compliant, with no issues noted. However, we identified issues with the recording of complaints. The safeguarding audit was scored at 94%, with the only recorded issue being management needed to complete Local Authority safeguarding training. It had not identified some safeguarding issues had not been reported to CQC, as required. Care plan audits had been completed for people whose records we viewed on assessment. However, despite this we still found issues with incorrect, inconsistent or contradictory information in these people’s records. We noted the ‘good governance’ audit had identified more audits were needed and a more robust auditing process required, However, it was not documented how this would be achieved.

A number of processes to assess the service and drive improvements had been introduced. These included the ‘resident of the day’ process, daily walk rounds and daily huddles, which were essentially daily meetings to discuss any issues or concerns and people’s care needs. However, we noted none of these had been completed consistently. From checking records, we noted in the previous 4 weeks, only 8 daily walk rounds, and 5 daily huddles had occurred. The deputy manager told us they sometimes things cropped up, which prevented them from being completed, but they aimed to do them at least 2 to 3 times per week.

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.

Since the last assessment, the provider had employed the services of a consultancy firm to provide advice and support with audits, governance, staff management and risk assessments. We asked about this during this assessment. The deputy manager told us, “The consultants have just finished their period of support. They did a provider level assessment, and provided advice on what needed to be done, this included actions linked to recruitment, governance and other areas. We have an action plan with all information included.”

We reviewed the provider’s ongoing action plan. We found this largely contained issues we had identified at last assessment along with issues identified by the consultancy firm, during their audit process. The action plan listed what steps had been taken to date to address any shortfalls. It was noticeable, the document was not being used to capture issues or actions generated from the provider's own governance processes. One of the issues we identified during this assessment, was where checks and monitoring had identified an issue or gap in practice, there was limited to no feedback recorded, to state what had been done to drive improvements. Since the last assessment, the provider had introduced a ‘lessons learned’ document. This was still a work in progress and was largely being used to review organisational areas for improvement, rather than those related to specific incidents or people’s care. Areas covered included care plans and risk assessments, historic and ongoing building maintenance, electronic systems and medicines procedures. For each entry, the provider had documented what the issues was, what lessons had been learnt and what had been put in place to address any shortfalls. It was not clear how this process tied in with the providers ongoing action and improvement plan.