We carried out a review of the data available to us about Malvern House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Malvern House, you can give feedback on this service.
We found the following examples of good practice.
The home was clean, hygienic and uncluttered in appearance. There were procedures to ensure that infection control risks were reduced. For example, increased cleaning of communal areas when the housekeeping staff were on duty. However, the cleaning schedule did not identify additional cleaning that staff carried out when people walked around the home. The registered manager said staff cleaned areas such as door handles following use.
Procedures were in place regarding self-isolation for people who showed symptoms of COVID-19 or who were admitted to the home from the community or other health care provision. The admission procedure had been reviewed and developed to reduce the risk of infection from COVID-19.
Due to the current national lockdown, visiting was currently restricted. Friends and families were provided with information on the current restrictions. Where visiting was permitted inside the home for compassionate reasons (for example for people receiving end of life care) suitable infection control procedures were in place when visitors entered and moved around the building. For example, visitors were accompanied around the building by staff, and only spent time in the person’s bedroom. Visitors were screened for COVID-19 prior to entering the home. Visitors were required to wear masks and, as necessary, other PPE.
Arrangements had been made for visitors to speak with and see friends and family through an open fire exit or through windows. This enabled social distancing to be maintained. People were supported to speak with their friends and family using IT and the telephone as necessary.
Appropriate testing procedures for COVID-19 had been implemented for all staff and people who used the service following national guidance regarding the frequency and type of testing.
Infection control policies and procedures had been updated in line with the national guidance relating to COVID-19 and staff were provided with verbal and emailed information when best practice recommendations were updated. The training for staff regarding infection control had been updated to include guidance relating to COVID-19.
The registered manager had completed risk assessments regarding the environment and risks to staff and people who used the service. The registered manager was aware of staff members who were at increased risk from COVID-19 and a plan had been agreed with the staff member should there be an outbreak in the home.
The provider had a contingency plan to manage an outbreak of COVID-19.
Plentiful supplies of personal protective equipment (PPE) were available in the home. Signage was in place throughout the home regarding the requirement for wearing PPE. Additional signage identified the PPE to be worn when a person was assessed at higher risk of infection.
The accommodation is on two floors, with access to the upper floor via stairs and passenger or chair lifts. Bedrooms have wash hand basins and vanity units. There are shared bathrooms, shower facilities and toilets. Shared living areas included a lounge, dining room, garden and outside seating area.
This was the first inspection for the service since it re-registered as a new legal entity in February 2018.
There was a registered manager in post who was responsible for the day-to-day running of the service. 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 and associated Regulations about how the service is run.
During the inspection we spent time in the shared living areas to observe staff interaction with people and how people responded to the care and support provided. We observed that people were relaxed and comfortable with staff, and had no hesitation in asking for help from them.
People and their relatives told us they were happy with the care they received and believed it was a safe environment. Comments included, “I came back here on respite because the staff make me feel safe”, “All the staff here work hard and are superb” and “The staff are so kind.”
People received care and support that met their needs because there was a stable staff team who had the skills and knowledge to provide responsive and personalised care. Staff knew how to recognise and report the signs of abuse. There were enough staff on duty to meet people’s needs.
Staff were supported in their roles by a system of induction, training, one-to-one supervision and appraisals. New staff completed a thorough recruitment process to help ensure they had the appropriate skills and knowledge.
Care plans contained personalised information about people’s individual needs and wishes. Risks were identified and included guidance for staff on the actions they should take to minimise any risk of harm. When people were assessed as needing to have specific aspects of their care monitored records showed this was well managed. Care plans and risk assessments were kept under regular review. Staff were provided with information about people’s changing needs through effective shift handovers and daily records.
Staff worked with healthcare professionals, such as tissue viability nurses, GPs and speech and language therapists to help ensure people had timely access to services to meet their health care needs. Care records were updated to provide staff with clear instructions about how to follow advice given by external professionals.
People were supported to eat a healthy and varied diet. Comments from people about their meals included, “The food’s pretty good”, “I like the bacon and egg sandwich I get for breakfast” and “It’s good to get lots of fresh vegetables.”
Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
There were safe arrangements in place for administration, storage and disposal of medicines. People were supported to take their medicines at the right time by staff who had been appropriately trained and medicines records were completed appropriately.
People were able to take part in a range of group and individual activities. These included puzzles, board games, reading books and craft work. External entertainers, such as singers and bell ringers, regularly visited the service as well as the local church. Staff supported people to keep in touch with family and friends and people told us their friends and family were able to visit at any time.
There was a management structure in the service which provided clear lines of responsibility and accountability. Staff had a positive attitude and the management team provided strong and supportive leadership. People, their families and healthcare professionals were all positive about the management of the service and told us they thought the service was well run.
People and their families were given information about how to complain and details of the complaints procedure were displayed at the service. The service sought the views of people, families, staff and other professionals and used feedback received to improve the quality of the service provided. There were effective quality assurance systems in place to make sure that any areas for improvement were identified and addressed.