Moulsham Home

Updated 1 December 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 carried out by 1 inspector and an Expert by Experience who made telephone calls to relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Moulsham Home 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. Moulsham Home 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 a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 17 November 2023 and ended on 24 November 2023. We visited the location's service on 20 November 2023.

What we did before the inspection

We reviewed information we had received about the service since the last 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 all this information to plan our inspection.

During the inspection

We spoke with 13 relatives and 1 person about their experience of the care provided. We used observations to help us understand the experience of care people received for people who could not talk to us. We spoke with 3 members of staff and the registered manager.

We reviewed a range of records. This included 3 care records and plans. We looked at 3 staff files in relation to recruitment and staff supervision and a variety of records relating to the management of the service.

Updated 1 December 2023

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

About the service

Moulsham Home is a residential care home providing the regulated activity of accommodation and personal care to up to 23 people. The service provides support to people with learning disabilities and dementia. At the time of our inspection 22 people were using the service.

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

The service was not always meeting the underpinning principles of Right support, Right care, Right culture. Improvements were needed to the systems and governance of the service to ensure people received safe care. We found concerns with the providers lack of oversight and poor recruitment practice.

Right Support:

Care and support were provided in a safe, homely, well equipped, well-furnished environment which met people's physical and sensory needs. People living at the service had adapted their bedrooms to their likings. People's independence was promoted.

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.

Right Care:

There was limited information in the support plans we reviewed relating to people's end of life wishes. We have made a recommendation about end of life wishes.

Care was planned and delivered in a way which was intended to ensure people's safety and welfare. There were enough staff to meet people's needs. There were systems in place to minimise the risk of infection. Medication was dispensed by staff who had received training to do so and assessed as competent.

Right Culture:

Support focused on quality of life and followed best practice. Staff involved people, their family and other professionals as appropriate to evaluate the quality of support given and obtain feedback to improve people's day to day quality of life.

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

Rating at last inspection

The rating at the last inspection was good (published 22 August 2017).

Why we inspected

We undertook a focused inspection to review the key questions of safe and well-led only. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating

You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Moulsham Home 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 have made a recommendation in relation to recruitment practices, management of when required (PRN) medicines, risk assessments, end of life wishes and quality assurances.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.