20 December 2023
During an inspection looking at part of the service
Heathfield House is a care home for people who may have a learning disability or autism. The service was registered for up to 6 people; 6 people lived there at the time of our inspection.
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
People’s experience of using this service and what we found
Right Support:
Care records did not always contain the accurate and up to date information required to keep people safe. Despite this, staff knew people’s care needs well and people and their relatives told us they felt safe and supported.
Records did not show that appropriate action was taken in response to incidents where people had fallen. Therefore, we could not be assured that action had been taken to reduce the risk of harm from falling.
The systems in place to monitor safety and quality at the service were not fully embedded or effective. The registered manager and provider did not always report notifiable incidents to us and the local authority.
Right Care:
There were sufficient numbers of suitable staff at the service. However, improvements were needed to ensure safe recruitment processes were consistently operated.
Staff supported people in line with their individual preferences and agreed care plans. People were supported to receive their medicines when they needed them and were protected from the risk of infection as staff followed safe infection prevention and control practices.
Right Culture:
People told us they were supported to have maximum choice and control of their lives. However, the requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards were not consistently applied. People were not always supported in the least restrictive way possible.
People were able to receive visitors without restrictions in line with best practice guidance.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was good (published 10 August 2018).
Why we inspected
This inspection was prompted by a review of the information we held about this service. We planned to complete a focused inspection to review safe and well-led only. However, due to concerns identified during the inspection with regards to the application of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards, we also reviewed the effective key question.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed to requires improvement. This is based on the findings at this inspection
You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for Heathfield House on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified regulatory breaches in relation to; the provision of safe care, the application of safeguarding processes, the processes in place for assessing and obtaining consent to care and the systems in place to assess, monitor and improve the quality of care at the service.
You can see what action we have asked the provider to take at the end of this full report.
We have made a recommendation about the processes in place to obtain feedback about the quality of care from relatives and staff.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.