Archived: Sholden Hall Residential Retreat

Updated 14 April 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 included checking the provider was meeting COVID-19 vaccination requirements. 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 one 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.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 24 February 2022 and ended on 4 March 2022. We visited the service on 24 February 2022.

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 used information gathered as part of monitoring activity that took place on 9 February 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

We spoke with three relatives about their experience of the care provided. We spoke with three people about their experience of living at the service. We spoke with four members of staff including the registered manager, deputy manager, heads of care and a team leader. We observed interactions between staff and people in the lounge and during the lunchtime meal.

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

After the inspection

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

Updated 14 April 2022

About the service

Sholden Hall Residential Home is a residential care home providing personal care to up to 27 older people who may be living with dementia. At the time of our inspection there were 20 people using the service. The service accommodates people in one large adapted building.

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

Relatives told us, they thought people were safe and happy living at Sholden Hall. People told us they were happy and felt safe living at the service. We observed people relaxed in the company of staff, smiling and laughing with them. People respond positively when asked if they were happy.

However, medicines were not always managed safely. People had not always received their medicines as prescribed and records were not accurate. Potential risks to people’s health and welfare had not been consistently assessed. There was no guidance for staff about how to support people to minimise risks and keep them safe.

When incidents had occurred, action had been taken to keep people safe. However, the registered manager had not always recognised when these incidents needed to be reported to the local safeguarding authority. The registered manager had not consistently notified the Care Quality Commission of incidents as required.

There was a system of checks and audits in place, including regular provider visits, but these were not effective and had not identified the shortfalls found at the inspection. People and relatives had not been asked for their opinion of the quality of the service.

Some areas of the service needed redecoration and could not be cleaned effectively. Visitors to the service were required to provide a negative Covid-19 test before coming into the service.

Accidents and incidents had been analysed and action taken to reduce the risk of them happening again. Staff were recruited safely; people were supported by enough staff to meet their needs.

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

Rating at last inspection

The last rating for this service was Good (published 11 October 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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. This included checking the provider was meeting COVID-19 vaccination requirements.

We undertook a focused inspection to review the key questions of safe and well-led only. We have found evidence that the provider needs to make improvements. Please see the Safe and Well Led sections of this full report

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 changed from Good to Requires Improvement based on the findings of this inspection.

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

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

Enforcement

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 management, mitigation of risks, checks and audits and good governance 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.