Archived: Hallcroft Care Home

Updated 24 September 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 9 and 10 August 2015 and was unannounced.

The inspection team consisted of a head of inspection, two inspectors, a specialist advisor with a background in nursing and an expert by experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection, the provider completed 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 improvements they plan to make. To help us plan our inspection we reviewed previous inspection reports, information received from external stakeholders and statutory notifications. A notification is information about important events which the provider is required to send us by law. We also contacted Commissioners (who fund the care for some people) of the service and other healthcare professionals and asked them for their views.

We spoke with nine people who used the service, four relatives, four members of the care staff, the cook, two nurses, deputy manager, regional manager, regional support manager and a managing director.

We looked at all or parts of the care records of eleven people along with other records relevant to the running of the service.

Some of the people who used the service had difficulty communicating with us as they were living with dementia or other mental health conditions. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 24 September 2015

We carried out an unannounced inspection of the service on 9 and 10 August 2015.

Hallcroft Care Home provides accommodation for people who require nursing or personal care. On the day of our inspection 21 people were using the service. There was a manager in place, but, at the time of the inspection they had not applied to become registered with the Care Quality Commission. At the time of publishing this report an application for the manager to become registered had been received.

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 for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During our previous inspection on 18, 19 and 20 February 2015 we identified five breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2010. These were in relation to people’s care and welfare, assessing and monitoring of the quality of service provision, consent to care and treatment, supporting workers and maintaining people’s records. During this inspection we found improvements had been made but further improvements were still needed.

People told us they felt safe at the home and people were supported by staff who understood how to identify and report allegations of abuse. Improvements had been made in the assessment of the risks to people’s safety, and accidents and incidents were appropriately investigated. Procedures were in place to evacuate people safely in an emergency. People told us there had been improvements in the time it took staff to respond when they pressed their nursing call bells, but further improvement was needed. Improvements had been made to the staffing team. There had been a significant decrease in the number of agency staff used at the home. Medicines were managed, administered and stored safely. However some gaps were identified on people’s medicine administration records regarding the application of creams.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The DoLS are part of the MCA. They aim to make sure that people are looked after in a way that does not restrict their freedom. The safeguards should ensure that a person is only deprived of their liberty in a safe and correct way, and that this is only done when it is in the best interests of the person and there is no other way to look after them. The manager had applied the principles of the MCA and DoLS appropriately although further applications for DoLS were required.

The majority of people told us the ability of staff to provide care that met their needs had improved. Induction procedures had been implemented for agency staff; however these had not always been appropriately completed. The majority of staff had received supervision of their work, although some staff had not. People told us they felt able to make their own choices and we observed staff respect people’s wishes. Some people spoke positively about the food provided whereas others felt improvement was needed. The lunchtime experience for people did not meet their needs; condiments and menus were missing and parts of the dining room floor were dirty. People had access to external healthcare professionals, although communication between staff and people regarding these appointments required improving.

People told us staff treated with them kindness and respect. Staff spoke respectfully with people and showed a genuine interest in what they had to say. The staff understood people’s personal histories and used that information when interacting with them. People were provided with information on how they could access independent advice about decisions regarding their care. People’s dignity was promoted and maintained. People’s friends and relative were able to visit them when they wanted to.

Improvements had been made to people’s care planning documentation. People had better access to activities and there was now an activities coordinator in place to assist people to do the things they want to do. People were supported to form meaningful relationships with others and to avoid social isolation. Staff had a good understanding of people’s preferences and used that information when interacting with them. People were provided with a complaints procedure, however this was not in an accessible place or provided in a format that could be easily understood.

There was a new management team in place; however the home manager was not registered with the CQC at the time of the inspection. Staff understood the aims and values of the service and people felt able to discuss concerns they had with the manager. Processes were in place to manage the risks faced by people and the service as a whole. Staff morale had improved since the last inspection and they felt the management team listened to them and valued their opinion. Robust auditing processes were in now in place although these had not been in place long enough for us to judge whether they could sustain the improvements made at the home.