Hamble Heights CQC Feedback and Action Plan 2023

Hamble Heights was inspected by the Care Quality Commission (CQC) in November 2022 and the report was finalised in January 2023.  The inspection took place over two full days and the inspectors reviewed our service thoroughly.  The final report judges the home as ‘Requires Improvement’ overall.  Whilst we are very disappointed by this outcome, we are encouraged that the key questions of ‘Caring’ and ‘Responsive’ remain rated ‘Good’.

The report’s findings are varied in terms of positives and negatives.  There were some areas that were very good, and other areas that need improvement.   Some examples of the positive comments included that the CQC observed that we provide enough staff to meet people’s needs and reported that residents were supported with their nutritional needs – receiving varied meals, including a choice of fresh food and drinks.  The CQC also recognised our staffs’ dedication to support residents and that they treated them with kindness and compassion.  The feedback from residents and relatives on this point was heartening,

“I believe my mother to be safe and she’s very happy with the care she receives and the pain and anxiety she suffered before her admission has gone as a result of feeling safe and secure at Hamble Heights.” 

The report also recorded that systems were in place to protect residents from abuse.  It stated that residents were supported to have maximum choice and control of their lives, and staff supported them in the least restrictive way possible and in their best interests.  The report positively noted that there was support and one-to-one sessions or supervisions for staff members to discuss areas of development, to encourage best practice and high standards of care.

However, under three of the key questions, ‘Safe’, ‘Effective’ and ‘Well-led’, we were judged as ‘Requires Improvement’.  This means that there are some elements within these categories where we could perform better.  Primarily, the findings flagged inconsistencies in recording, which we are fixing through a complete reprogramming of Nourish. We have dedicated a full-time person that will be working with the Home Manager to achieve this successfully.

We have broken the report down below into a summary of the areas that require improvement, which shows you what the CQC have said, and what we either have done to rectify it, or what our plan of action is to make the improvements necessary.

What CQC reported What we have done / are doing about it
Risk assessments for residents’ needs required more robust recording.
  • We always assessed and managed the risks; however, our record keeping was not as clear as it should be. As such, we have repositioned this element on Nourish, the care planning software, to ensure efficiency.
  • We have reviewed every single care plan to ensure all information is accurate.
Effective management of fire evacuations required
  • We had one outstanding task that has now been completed.
  • We have updated our environmental audits and assessments for a more accurate overview.
  • We have now held (and scheduled future) fire evacuations at night.
Medicines administration records (MAR) confirmed people had received their medicines as prescribed. However, they found some instances of medicine management that was not always safe.
  • Our central clinical team has reviewed all clinical records and made improvements.
  • Our Clinical Lead post was vacant just prior to the inspection, however, Maria Micu has now been in post for more than 6 weeks.
  • We have sought regular feedback from health professionals who have responded that they are happy and satisfied with how medications are managed at Hamble Heights.
Governance systems were not always effective in promoting a person-centred culture.
  • We have changed how we monitor the compliance and quality to improve effectiveness.


Our aim is to be always honest and transparent – and especially when we do not get things quite right.  We will work tirelessly to successfully deliver our robust CQC action plan and to earn comments from residents, such as these that the CQC reported: “I don’t feel worried about anything. I feel safe.”  “I absolutely love it here.”