Goodwins Hall Care Home

Updated 28 September 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

Consisted of 2 inspectors, 1 specialist medicine inspector and 2 Experts by Experience (ExE). An ExE is a person who has personal experience of using or caring for someone who uses this type of care service service.

Service and service type

Goodwins Hall 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. Goodwins Hall 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 new manager in post, but they had not started the registration process to become the registered manager at the time of our inspection. We will refer to them as “the manager” throughout the report.

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 (PIR). 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 reviewed information we held about the service on our systems and liaised with the local authority quality assurance team. This information assisted us with the planning of this inspection.

During the inspection

We spoke with members of staff including the manager, nominated individual (The nominated individual is responsible for supervising the management of the service on behalf of the provider), regional director, 2 members of nursing staff, 4 care staff and members of the kitchen team. We spoke 13 people living at the service and observed care provided in communal areas. We spoke with 3 relatives about the care and support provided.

We reviewed a range of records, including 4 people's care records and 16 medication records and observed some of the medicine rounds. We looked at 2 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

We continued to seek clarification from the provider to validate evidence found.

Updated 28 September 2023

About the service

Goodwins Hall Care Home is a care home, providing nursing and personal care to up to 78 people. The service provides support to people with nursing care and support needs. At the time of our inspection there were 71 people using the service. The care home accommodates people across two floors and each floor is divided into units named Kingfisher, Skylark and Canary. The service provides care to people living with physical healthcare needs, and some people were living with dementia.

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

People were not always receiving their medicines on time in line with health care professional’s recommendations. Medicines were administered later than required, or they were not given at regular intervals across the day to achieve the best outcome.

People were not consistently protected from the risk of accessing items such as razors, denture cleaning tablets, and medicines without staff supervision, as there were no lockable storage units for such items to be kept in, which increased their risk of harm.

People’s care records needed to be reviewed to ensure they were an accurate reflection of individual support needs and preferences, for example how they liked to take their medicines.

Improvements were needed to the provider’s level of oversight of this service, to ensure people were kept safe, particularly in the absence of having a registered manager in post. Some of the provider’s own audits and checks had not identified shortfalls found during this inspection to ensure care people received as consistently of a high standard.

People 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 policies and systems in the service supported this practice.

There was an ongoing refurbishment plan in place to ensure improvements to the condition of the care environment, with plans to improve the condition of external paving to improve accessibility.

People were supported by suitably trained, competent staff, and staffing levels were found to be above the assessed levels of dependency to meet people’s individual care needs.

Overall, cleanliness within the service was a good standard, and people’s bedrooms were individually decorated to make them feel homely and personalised. Procedures in place, and observations during the inspection demonstrated staff were protecting people from the risks of the spread of infection and were following the provider’s policies in place.

The manager and provider team were responsive and open to inspection feedback, and were keen to drive improvement at the service to ensure people received consistent standards of care.

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

Rating at last inspection and update The last rating for this service was good (published 18 September 2019). We also completed an unrated inspection which was published on 16 March 2023 following a serious incident which happened at the service.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We had also received concerns in relation to the management of people’s safety prior to this inspection. We undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements in relation to the management of people’s risks, particularly in relation to medicines and the care environment. Please see the safe and well-led sections of this full report.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.