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Halsey House Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 May 2020

About the service

Halsey House provides accommodation, nursing and personal care for a maximum of 89 people, some of whom may be living with dementia. The dementia unit is a separate unit from the main building, which holds provision for people requiring nursing and residential care. At the time of the inspection there were 66 people living at the service.

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

Overall, we saw improvements in the care and support provided at the service, since our last inspection. However, we continued to identify some concerns in relation people’s medicines management, the recording of aspects of people’s care, and the management of certain environmental risks to ensure people’s safety. Leadership and governance arrangements within the service were evolving, and aspects of the improvements made were yet to be fully embedded. Whilst audits were being completed, we continued to find some shortfalls which had not been found by the service. There remained breaches of regulations impacting on aspects of the quality of service provided to people.

We received mixed feedback regarding staffing levels and food quality, however we received positive feedback regarding the levels of activities people were able to access, and their ability to maintain their hobbies, interests and social networks. Staff treated people with kindness and were polite, and we received positive feedback from people and their relatives about the care provided.

Management plans were in place for people needing support at the end of their life. The service told us they had good working relationships with health and social care organisations to ensure people received joined up care.

The interim manager encouraged staff, people and their relatives to give feedback on the service and areas for improvement, through questionnaires and regular meetings. Overall, staff morale had improved since the last inspection.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive ways possible; policies and systems in the service were followed to support good practice. Improvements had been made to the assessment of people’s capacity since the last inspection.

We have made recommendations relating to the effective deployment of staff and monitoring people’s fluid levels.

Rating at last inspection and update

The last rating for this service was Requires Improvement, with Inadequate for well-led (published 27 November 2019). There were three breaches of the regulations. Following the last inspection, we placed conditions on the provider's registration. This meant the provider was required to send us monthly action plans to show what action they were taking in response to the concerns we found. These conditions will remain in place as the provider still needs to continue to make improvements.

Why we inspected:

This was a comprehensive inspection, completed in line with our inspection schedule.

Enforcement

We have identified repeated breaches of regulation in relation to safe care and treatment and good governance arrangements. Please see the actions we have told the provider to take at the end of this report.

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. The provider will continue to submit monthly action plans in line with the conditions in place on their registration.

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

Inspection areas

Safe

Requires improvement

Updated 5 May 2020

The service was not always safe.

Details are in our safe findings below.

Effective

Good

Updated 5 May 2020

The service was effective.

Details are in our effective findings below.

Caring

Good

Updated 5 May 2020

The service was caring.

Details are in our caring findings below.

Responsive

Good

Updated 5 May 2020

The service was responsive.

Details are in our responsive findings below.

Well-led

Requires improvement

Updated 5 May 2020

The service was not always well-led.

Details are in our well-Led findings below.