Goole Hall

Updated 15 June 2022

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

The inspection was completed by two inspectors on the first day, and one inspector on the second day.

Service and service type

Goole 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. Goole Hall is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post. A new manager had been recruited but had not yet registered.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We contacted the local authority safeguarding and commissioning teams and the local infection control team for feedback. We also looked at information sent to us since the last inspection. This included information the provider is required to send about incidents at the service. 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 used all this information to plan our inspection.

During the inspection

We spoke with two people who used the service and three relatives. We also spoke with two care staff, the manager, the senior management team and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We looked around the home to review the facilities available for people and the cleanliness of the service. We also looked at a range of documentation including two people’s care files and medication administration records. We looked at three staff files and reviewed documentation relating to the management and running of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data, care records, policies and other records relating to the management of the service.

Updated 15 June 2022

About the service

Goole Hall is a residential care home which is registered to provide personal care and accommodation for up to 28 older people, some of whom may be living with dementia. At the time of the inspection, 15 people were using the service. The building has three floors and a lift which operated between all levels.

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

Records did not always support staff to administer people’s medicines when they needed them. The provider had reviewed and updated their quality assurance systems, though they had not identified all shortfalls found during the inspection.

Systems were in place and staff understood how to keep people safe from harm and abuse, though staff were not always sure where to find safeguarding information. We have made a recommendation about safeguarding. Risks to people’s safety and wellbeing had been identified and were monitored and managed by staff. Accidents and incidents were monitored to support learning from them and reduce the risk of them happening again, though systems required further improvement.

Staffing levels were safe and enabled staff to support people in a timely manner. People took part in meaningful activities. Recruitment processes supported the safe recruitment of staff, though records did not show gaps in employment history had been explored. We have made a recommendation about recruitment.

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.

People were appropriately supported to eat and drink and people had access to a varied diet. We have made a recommendation about fluid monitoring systems. Staff worked with relevant healthcare professionals to meet people’s needs. Staff had the required skills and knowledge to support people.

The senior management team were supporting the service and we received positive feedback regarding the new manager.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 07 July 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found that although some improvements had been made the provider remained in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last two inspections.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 25 February and 01 March 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, need for consent, staffing and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Goole Hall on our website at www.cqc.org.uk.

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.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to medicines and quality assurance 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.