Focused inspection of Heartwell House found enough improvements had been made to no longer be in breach of Regulations 12 and 17, with Safe improving to Good. However, Well-led remained Requires Improvement due to no registered manager, inconsistent CQC notifications, and weaknesses in care plan clarity and IPC audits.
Concerns (6)
moderateGovernance: “The provider had not consistently notified CQC about significant events such as incidents, accidents and where there were restrictions placed on people's live.”
moderateLeadership: “The service had no registered manager. The provider told us a suitable person had been identified but the appointment was not confirmed.”
moderate
Care planning
: “The changes made to people's care plans and the DoLS care plans were not always clear for staff to follow.”
minorRecord keeping: “it was difficult to establish when they were last reviewed as none were dated”
minorInfection control: “The infection prevention control audit had not identified two dining room chairs had damaged outer covers”
minorInfection control: “There was no ventilation in the laundry room.”
Strengths
· Safe staff recruitment procedures including DBS and reference checks
· Low staff turnover supporting consistent care from staff who knew people well
· Staff trained in safeguarding and knew how to report concerns
· Medicines administered safely with STOMP principles applied
· Service working within the principles of the Mental Capacity Act with appropriate DoLS authorisations
Quality-Statement breakdown (10)
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated
Heartwell House was rated Requires Improvement overall, with Well-led deteriorating to Inadequate, due to continued breaches of Regulations 12 and 17 around insufficient staffing and unsafe environment (missing window restrictors, accessible building site). Warning notices were issued, although medicines, recruitment, safeguarding and caring interactions remained satisfactory.
Concerns (9)
criticalStaffing levels: “On the day of our inspection, staffing levels were not sufficient to meet people's needs. Some staff had called in sick, and replacement staff had not been found.”
criticalStaffing levels: “The provider failed to ensure that staffing levels met people's individual assessed needs. Funding made available by the local authority for individuals was not being utilised”
criticalGovernance: “Audits were conducted, but prompt action was not always taken to resolve any issues found including staffing shortage and the environment.”
criticalGovernance: “Audits and checks had not identified the lack of window restrictors in some first floor rooms.”
criticalLeadership: “there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
criticalOther: “Not all of the windows on the first floor of the building had window restrictors on them... A door to an outside area was fully accessible to residents, and led on to a small building site”
moderatePerson-centred care: “We saw people sitting in the communal area for long periods of time without any interaction from staff, who were busy with other tasks.”
moderateCommunication with families: “major building work had begun at the service, but people were not consulted about it by the provider, and staff had not had time to prepare for any disruption”
moderateInfection control: “Staff told us they felt that cooking in the kitchen immediately after being on cleaning duties throughout the service, could provide an infection control risk.”
Strengths
· Medicines were stored and administered safely with accurate MAR records
· Safe staff recruitment checks were in place with appropriate pre-employment checks
· Staff treated people with kindness, dignity and respect; positive interactions observed
· Staff were trained in safeguarding and knew how to report concerns
· Service was clean and well maintained; PPE used effectively
Quality-Statement breakdown (10)
safe: Staffing and recruitment; Assessing risk, safety monitoring and managementRequires improvement
safe: Preventing and controlling infectionNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Using medicines safelyNot rated
safe: Learning lessons when things go wrongNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careInadequate
well-led: How the provider understands and acts on the duty of candourNot rated