This inspection was an unannounced and took place on the 26 March and 3 April 2018.

Heaton Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided and both were looked at during this inspection.

We last carried out a comprehensive inspection of this service on 25 and 27 July 2017. At that inspection we found four repeat breaches and four new breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. The repeat breaches were because systems of recruitment were not sufficiently robust, premises were not always maintained securely, people were not protected against the risk associated from unsafe or unsuitable premises and systems of governance were not sufficiently robust. The four new breaches were because medicines were not managed safely, lack of staff supervision, the provider had failed to provide information requested by CQC and had not displayed on their website a copy of the most recent rating by CQC. The service was given an overall rating of inadequate and was placed in special measures.

Following the last inspection, we imposed conditions on the provider’s registration that required them to complete an improvement action plan to show how they would improve the key questions; safe, effective, responsive and well led to at least good. We also made one recommendation; that the service improves documentation of reviews of care and peoples involvement in those reviews.

During this inspection we looked to see if the required improvements had been made. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to the safe management of medicines. However we found that significant improvements had been made in all other areas. Due to our findings at this inspection the service has been taken out of Special Measures’

Heaton Lodge is a large detached property in its own grounds. It provides care and accommodation for up to 23 people, between the ages of 18 and 65 years, with mental ill health. The service may also accommodate up to four persons over 65 years. At the time of our inspection there were 21 people living at the service.

The service did not have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The manager of the service had applied to be registered with CQC just prior to our inspection. People who used the service spoke very highly of the manager and the way the service was run. Everyone was very positive about the changes since out last inspection.

Medicines were not always managed safely. Staff were not provided with sufficient information about medicines that were to be given 'when required'. Records of stocks of medicines were not always accurate. You can see what we asked the provider to do at the back of this report.

Appropriate window restrictors were now fitted and equipment was maintained and serviced appropriately. Health and safety checks, including fire safety were completed. There was a system in place to ensure the building was maintained appropriately. Improvements had been made to the furnishings and décor of the building.

Recruitment procedures were in place which ensured staff had been safely recruited. There were sufficient numbers of staff to meet people’s needs. Staff received the training, support and supervision they needed to carry out their roles effectively.

The provider had displayed the CQC rating in the home.

Risks to people who lived at the service were well managed. Accidents and incidents

This was an unannounced inspection which took place on the 25 and 27 July 2017.

We had previously inspected the service in February 2016 when we identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because systems of recruitment were not sufficiently robust, premises were not always maintained securely, people were not protected against the risk associated from unsafe or unsuitable premises and systems of governance were not sufficiently robust. This resulted in us making four requirement actions.

During this inspection we checked if the required improvements had been made. We found the provider was still in breach of those regulations.

We also found a further four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

These related to the proper and safe management of medicines, lack of staff supervision, the provider had failed to provide information requested by CQC and had not displayed in their website a copy of the most recent rating by CQC.

You can see what action we told the provider to take at the back of the full report. We are currently considering our options in relation to enforcement in response to some of the breaches of regulations identified. We will update the section at the back of the inspection report once any enforcement work has concluded.

We also made one recommendation; that the service improves documentation of reviews of care and peoples involvement in those reviews.

Heaton Lodge is a large detached property in its own grounds. It provides care and accommodation for up to 23 people, between the ages of 18 and 65 years, with mental ill health. The service may also accommodate up to four persons over 65 years. At the time of our inspection there were 23 people living at the service.

Systems of recruitment were not sufficiently robust and did not ensure all required pre-employment checks had been made.

We found that not all windows were fitted with appropriate restrictors. This did not follow the Health and Safety Executive (HSE) published guidance on the use of window restrictors in care homes. Appropriate window restrictors prevent the windows in care home from being opened too widely and prevent people falling from the windows.

The last electrical installation report, which gives information about the suitability of the electrical systems, had recommended a reinspeciton after two years. This had not been followed up. Equipment and services within the home had been serviced and maintained in accordance with the manufacturers' instructions. Some people had been smoking in their bedrooms and steps taken to protect people from the risk of harm were not sufficient. There was a lack of checks in relation to fire safety and water temperatures.

There was a lack of systems to monitor and improve the quality of the service. We found checks and audits that were carried out by staff within the home were incomplete and not sufficiently robust to ensure best practice was followed and compliance with regulations.

Medicines were not managed safely. Staff were not provided with sufficient information about medicines that were to be given ‘when required’. Records indicated that medicines storage temperatures were not being taken to ensure medicines remained effective and no action had been taken to rectify the problem. Records of stocks of medicines were not accurate.

Staff had received the training and induction they needed but had not received the supervision they required to support them to carry out their roles effectively.

In October 2016 CQC asked the provider to complete a Provider Information return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and what improvements they plan to make. The provider did not return the information we requested which is a legal requirement.

It is also a legal requirement that provider di

This inspection was carried out over two days on the 10 and 11 February 2016. Our visit on 10 February was unannounced.

We last inspected Heaton Lodge in July 2014 when it was found one regulation relating to assessing and monitoring the quality of service provision was not being met. The provider sent us an action plan telling us how they intended to meet this regulation. We carried out a follow up inspection in February 2015 where we found the action taken by the provider meant this regulation had been met.

Heaton Lodge provides care and accommodation for up to 23 people, between the ages of 18 and 65 years, with mental ill health. The service may also accommodate up to four persons over 65 years.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility about how the service is run.

We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Staff we spoke with had a clear understanding of their role in protecting people and making sure people remained safe and free from harm.

People who used the service, who we asked, said they felt save living in the home.

Although people who used the service told us they felt safe we found some areas in the home where people’s safety was being compromised. We saw that most electrical equipment had been portable appliance tested (PAT) but some items had not.

During our tour of those bedrooms we were able to enter, including one which we were unable to enter, we could see and smell that some people had been smoking in their rooms, which went against the organisations policy and procedure about no smoking on the premises.

We found that medicines were managed safely.

People spoke positively about the staff who they felt were supportive, kind and caring and we saw good interactions taking place between the staff team and people who used the service.

Staff had access to a range of appropriate training and were receiving supervision on a regular basis and felt management to be approachable and supportive.

Those care plans seen contained sufficient information to guide staff on the care and support people required. Where able, people had been involved and consulted about the development of their care plans. This helped to make sure people’s wishes were considered and planned for.

Care records seen indicated that people using the service had access to other health and social care professionals, such as the community mental health team, social workers and doctors.

Appropriate arrangements were in place to access and monitor if people were able to consent to their care and treatment and staff we spoke with had a good understanding of the care and support people required.

Records were kept of the food served and if concerns were identified about a person's nutritional intake, referral had been made to other health care professionals, such as a dietician.

People who used the service had access to a complaint procedure and knew who to speak with should they have any concerns, worries or complaints.

The registered manager told us that they monitored and reviewed the quality of service on a monthly basis by carrying out audits (checks) on all aspects of the management of the service for example, care plans, infection control, medication and the environment. During our examination of these completed audits, we noted that none of the concerns we raised during this inspection about the environment had been ‘picked up’ during the monthly audit process.

Recruitment of staff was not always carried out robustly.

The inspection team was made up of one inspector. We set out to answer the question is the service well led?

Below is a summary of what we found. The summary is based on speaking with the manager of the service, the care manager and from looking at records.

Is the service well led?

We found the service to be well led. The service had a manager who had applied to the Care Quality Commission (CQC) to become the registered manager of the service. The manager was supported by a skilled and experienced care manager who took charge of the service in the absence of the manager.

The manager was responsible for leading the quality assurance systems and for introducing and supporting the development of best practice in the service.

We carried out this inspection because we had received information that concerned us. The manager of the home told us that they had been in post for four months and had a number of issues of concern themselves and that they had put plans in place to improve the home.

We looked at safeguarding arrangements in place at the home and we had concerns that the policy was not up to date and the staff were not trained.

We looked at the staffing levels and we had concerns as there were not always enough staff on duty in the home and there was not always a senior member of staff on duty.

We looked at the support arrangements in place for staff and we had concerns. The staff were not receiving adequate training, support and supervision to do their jobs effectively.

We visited Heaton Lodge on 27 December 2012. We saw that the home was warm there were adequate numbers of staff on duty at the time of our visit. We observed that staff delivered care competently and efficiently and treated the people who used the service with respect and courtesy whilst offering support.

We looked at a sample of four care plans and saw that the information contained within them was factual. Some reviews were not up to date, but clearer new style care plans were being implemented, which would be easier to follow and keep up to date. There was evidence of good partnership working with other agencies, eg out patients, dentists and GPs.

We spoke with four people who used the service. One person told us “All the staff are nice and polite”, another told us “I am happy here, I don’t want to move, staff are very helpful.”

We looked at policies and procedures and noted that appropriate policies were in place, the safeguarding policy was being updated at the time of the visit, to be completed by end of January 2013. We spoke with two staff members who demonstrated an understanding of safeguarding issues and were aware of how to report and record any issues that may arise.

We saw evidence of a residents’ survey and saw that the results had been analysed and actions were being taken to address issues raised. We saw minutes of residents’ meetings where people who used the service could air their views and bring up any matters they wished to discuss.

People using this service told us that they liked the staff and that they were happy living at the home.

All people spoken to confirmed that staff respected their privacy and dignity and were given choices about how they spend their time.

Some comments we received from people living at Heaton Lodge were:

“The staff are very nice”.

“The staff treat me well”.

“I like the staff they are kind”.

“It’s up to me what I do”.

“I do go out quite a lot. I like to go for a curry and I like going to the cinema”.

“I just ask the staff and then I go out if I want to”.

“I have been to Lyme Park, the zoo, Blackpool and I like the discos we have”.

All the people spoken to said they felt safe living at Heaton Lodge and one person said “You can speak to any of the staff about anything”.

Advocacy services were available if people needed independent support.

During our inspection we spoke with the home’s manager, the performance manager and two members of support staff. We took a tour of the building, and spent some time observing the interactions between staff and the people who lived there. We also spoke with three people who used the service. We looked at a selection of the provider’s policies and records, including a sample of people’s care records. Following our inspection we spoke with two professionals who had visited Heaton Lodge and provided support to people who used the service.

We considered the evidence collected under the outcomes and addressed the following questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. Please read the full report for the evidence supporting our summary.

Is the service safe?

We saw that people were treated with respect by staff. People we spoke with who used the service told us they felt safe living at Heaton Lodge and with the support they received. One person commented “I don’t want to go elsewhere, I’m settled”.

We saw that there were effective measures in place to identify and manage the risks of abuse, and where allegations of abuse were made, to respond appropriately. We spoke with staff, who showed a clear understanding of how to identify abuse and the action they would take if they had concerns about the welfare or safety of people who lived at Heaton Lodge.

Is the service effective?

We saw that assessments were carried out to identify risks to the person’s health, safety or well-being and the support they required. People’s care plan records provided clear guidance to care staff in how to deliver care. We spoke with three people who used the service; they all made some positive comments about the service they received. One person told us they had been well since they had lived at Heaton Lodge and had not required any hospital treatment during their stay.

We saw that the service worked with other professionals involved in people’s care. Where other professionals were involved, this was clearly documented in people’s care plan records. The people we spoke with who lived at Heaton Lodge told us they had access to other people involved in their care, such as GPs or local mental health teams. Following our inspection we spoke with two professionals who had visited Heaton Lodge and provided support to people who used the service. They both made positive comments about the engagement they had had with Heaton Lodge staff and commented that staff knew the people they were supporting well.

We saw that staff were supported in their role by the management team and were provided with training to enable them to carry out their role competently.

Is the service caring?

We saw that staff treated people with respect and warmth and the support we observed was provided in a sensitive, personal way. The people we spoke with made positive comments about the care they received. We saw that people had been involved in developing their own care plans, including one person who used the service who had written their own care plan, which had been included in their care plan record.

Is the service responsive?

We saw that people’s care plan records reflected their individual needs. People using the service and their representatives had been involved in developing their care plans, which had been regularly reviewed to ensure they met the person’s needs.

Is the service well led?

The staff we spoke with told us the management team was approachable and supportive. Staff were provided with information about the needs of the people they supported, which provided them with guidance in how to deliver people’s care.

We saw that there was an established management structure in place with clear lines of accountability. However we found that the service did not have a formal quality monitoring system in operation. This meant that there was not a robust system in place to reliably identify and monitor risks or shortfalls in the service provided to people or formalise actions to minimise risks or improve the service.

The management team were unaware of the requirement to formally notify us of incidents relating to the service in certain circumstances, such as a person using the service sustaining a serious injury or disclosing safeguarding allegations.

Prior to our inspection we were made aware that this service had been issued with an enforcement notice by Greater Manchester Fire and Rescue Service following an unsatisfactory fire safety inspection. We have asked the provider about the actions they have taken to ensure they are compliant with fire safety regulations.