Minchinhampton Centre for the Elderly - Horsfall House

Updated 12 January 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors and an Expert by Experience carried out this inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Minchinhampton Centre for the Elderly – Horsfall House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Minchinhampton Centre for the Elderly – Horsfall House is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of monitoring activity that took place on 10 October 2022 to help plan the inspection and inform our judgements.

We sought feedback from the local authority and reviewed information we have received about the service. We used all this information to plan our inspection.

During the inspection

We spoke with 8 people who use the service and 2 relatives to gain their views of the service provided. We spoke with the registered manager, operations manager, 1 unit manager, 3 nurses, 4 care staff, 2 housekeepers, the activity co-ordinator, 2 maintenance staff and 1 work experience student. We gathered feedback from 1 health care professional. We reviewed 3 people’s care records and records pertaining to 6 people’s medicines administration. We looked at other records pertaining to the management of medicines including for medicines administered covertly (hidden). We reviewed records relating to the Mental Capacity Act and best interest decisions.

We reviewed records relating to the management of the service which included, 4 staff recruitment files, safety checks, maintenance records, risk assessments, audits, accidents and incidents and staff training.

Updated 12 January 2023

About the service

Minchinhampton Centre for the Elderly – Horsfall House is a residential care home providing personal and nursing care to up to 44 people. The service provides support to older people and people who live with dementia. At the time of our inspection there were 41 people using the service.

People were accommodated in one adapted building in two separate units. Each unit could support 22 people. One unit provides general nursing care and the other specialises in providing care to people living with dementia.

People’s experience of using this service and what we found

Environmental risks had been assessed but records relating to these did not always provide the information needed to show the provider had taken sufficient action to reduce or mitigate risks.

People’s care records did not always reflect the support staff told us they provided to keep people safe. This meant staff may not always have access to the information they require to reduce or mitigate people’s risks.

Robust staff recruitment processes had not always been followed to ensure safe recruitment of staff took place.

The provider had not ensured effective systems were in place to assess, monitor and improve the service and to ensure compliance with necessary regulations.

The required notification had not been made to us (the Care Quality Commission) when Deprivation of Liberty Safeguards (DoLS) had been authorised. This is required to support the monitoring of legally authorised DoLS. However, where required appropriate application to the local authority for DoLS had been made. Staff worked within the principles of the Mental Capacity Act 2005 and supported people to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There were enough staff employed to meet people’s care needs and to keep people safe. Successful staff recruitment had led to a reduction in the use of agency staff.

There were arrangements in place to protect people from abuse and discrimination and to identify poor practice and act on this.

We made a recommendation about a practice which could be open to abuse.

People’s medicines were managed safely. There were arrangements for medicines to be reviewed by people’s GPs. People told us they felt safe and well cared for and their relatives were satisfied with the care provided.

The registered manager provided strong leadership and support to the staff team. They were visible and available to people and their relatives for support and advice. Staff worked collectively across the care home to support good outcomes for people.

The service worked closely with commissioners of care and the provider’s day care services to ensure people could access the service as required. There were strong links with local primary healthcare services, community leaders and community groups to improve the quality of the service provided to people.

The provider was motivated to make improvements to the service and provided us with an update on their proposed actions for improvement. These actions related to safeguarding people from abuse, fire safety, Legionella risk, maintenance and safety checks (including relevant records), staff recruitment, submission of notifications to CQC and quality monitoring systems and processes.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 7 September 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this full report.

We sought some immediate information from the provider following our inspection on what action they will take to mitigate risks.

You can see what action we have asked the provider to take at the end of this full report.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. For those key questions not inspected, we used the ratings awarded at the last rated inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Minchinhampton Centre for the Elderly – Horsfall House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to records pertaining to the management of people’s and environmental risks, staff recruitment, notifications of authorised Deprivation of Liberty Safeguards and the provider’s governance and quality monitoring processes at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.