Sholden Hall Residential Home

Updated 24 May 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

The inspection was completed by an inspector.

Service and service type

Sholden 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. Sholden 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 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 registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we held about the service. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.

During the inspection

We spoke with 2 relatives about their experience of the care provided. We spoke with 4 people about their experience of living at the service. We spoke with 6 members of staff including the registered manager, deputy manager, provider, team leader and care staff.

We reviewed a range of records. This included 6 people’s care plans and all the medication records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service, including checks and audits.

Updated 24 May 2023

About the service

Sholden Hall Residential Home is a residential care home providing personal care to up to 27 people who maybe living with dementia. At the time of our inspection there were 26 people using the service. The service accommodates people in one large, adapted building.

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

People told us they felt safe living at the service. Relatives told us they felt their loved ones were safe and happy living at Sholden Hall.

However, potential risks to people’s health and welfare had not been consistently assessed and there was not always guidance for staff to mitigate risks. Environmental risks had not been fully assessed, doors to the stairs had not been secured, placing people at risk of falls.

There were not always enough staff to support people and keep them safe, especially during the night. There was a training system in place, but staff had not always received practical training such as moving and handling. Medicines were not always managed safely.

Checks and audits had been completed but these had not been effective in identifying the shortfalls found at this inspection. Accidents and incidents had been recorded, these had been analysed to identify any individual patterns and trends. However, the analysis had not been undertaken to identify patterns and trends linked to staffing and the environment.

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 were effective systems in place to protect people from discrimination and abuse. People were referred to health care professionals when their needs changed and staff followed the guidance provided.

People were supported to eat a balanced diet, they were offered a choice of meals, drinks, and snacks throughout the day.

People, staff, and relatives were asked their opinions about the service. People and relatives told us they knew how to complain, and the management team were responsive and dealt any concerns quickly.

People had anticipatory plans in place for when they required end of life care. Staff respected people’s privacy and supported them to be as independent as possible.

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

Rating at last inspection

This service was registered with us on 8 April 2022, and this is the first inspection. The last rating for the service under the previous provider was requires improvement, published on 14 April 2022.

Why we inspected

The inspection was prompted in part due to concerns received about risk management and staffing levels. A decision was made for us to inspect and examine those risks.

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

We have identified breaches in relation to management of risk, medicines and oversight of the quality of the service 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.