Last updated: 9 February 2026
"Positive culture and good staff training, but unreported falls without risk reviews, an overloaded manager with no deputy, and delayed recruitment checks hold it back."
When people fell, their risk of falling again was not always reviewed which meant action was not always taken to reduce the risk of harm from further falls. None of these had been reported to the local authority as potential omissions of care/neglect as required.
There was a positive and open culture at the service. People, relatives and staff spoke positively about Heathfield House. Comments included, 'I love working here, it feels like a family'.
Improvements were needed with recruitment to ensure staff were safe to work with people. The required pre-employment checks were not always completed in a timely manner, this included obtaining appropriate references and requesting DBS checks.
Staff told us the induction and training they received prepared them for their role. Training records showed that most staff were up to date with their required training.
The registered manager had been required to provide direct care and support to people which resulted in them having less dedicated time to complete management tasks. There was no deputy manager or senior care worker to support the registered manager.
People told us and care records showed they were supported to do the things they enjoyed both at the service and in the local community. People were asked for feedback about their care in the form monthly reviews. This was focused on activity provision.
Staff did not always report serious falls to the local authority or review risks to stop more falls happening.
Incident and accident records reviewed showed a total of 5 incidents relating to 3 people who had fallen in 2023 where injuries obtained required first aid or emergency medical care/advice. None of these had been reported to the local authority as potential omissions of care/neglect as required.
The manager has to do a lot of hands-on care and driving, leaving less time for oversight, and there is no deputy to help.
The registered manager had been required to provide direct care and support to people who used the service which resulted in them having less dedicated time to complete management tasks. There was no deputy manager or senior care worker to support the registered manager.
Recruitment checks like references and background checks were delayed without assessing the risks of new staff starting early.
The required pre-employment checks were not always completed in a timely manner, this included obtaining appropriate references and requesting DBS checks, to ensure staff were safe to work with people. Where there were delays... risks assessments were not completed.
AI Generated
Last inspected: February 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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