Archived: Masson House

Masson House is a residential care home providing accommodation and personal care to up to 17 people. The service primarily provides support to older adults but can also support people over the age of 18. At the time of our inspection there were 12 people using the service. The care home is a large adapted domestic style building, which also has a purpose-built ground floor extension.

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

The purpose of this inspection was to check whether the provider had complied with the conditions we had imposed on their registration with CQC, which took effect on 3 October 2023. We had imposed conditions because we found the provider needed to take urgent improvement action to keep people safe from harm. In this inspection we found the provider had not complied with the conditions and people continued to be at risk of harm.

The provider had not complied with the condition on their registration which stated they should send us evidence of their process and procedure for reviewing incidents and identifying safeguarding concerns. This meant people were still at risk of potential abuse and neglect.

The provider had not complied with the condition on their registration which required them to send us written confirmation that all sinks, baths, and showers, to which people had access, had appropriate thermostatic mixing valves fitted to ensure the hot water was at a safe temperature. This meant people were still at risk of harm from scalding.

The provider had not complied with the condition on their registration which required them to send us written confirmation that all radiators and associated pipework had appropriate covers in place that were securely attached to the wall. This was to prevent people encountering hot surfaces which may cause burns.

The provider had not complied with the condition on their registration which required them to send us written confirmation of their plans for repairing or replacing the lift. The lift was broken, and the provider told us it could not be easily repaired. This meant people could not use the lift to travel from the ground floor to their upper floor bedrooms.

The provider had not complied with the condition on their registration which required them to provide us with written details of their procedures for identifying, and addressing, environmental safety issues at Masson House; which impacted on the health and safety of the people who lived there. This included details of the timescales for completion of remedial works and who would be responsible for completing them.

The provider had not complied with the condition on their registration which required them to carry out a Legionella risk assessment and a fire risk assessment at Masson House. Additionally, the provider was required to send us confirmation those risk assessments had been completed, and a copy of their action plan to show how and when identified improvement actions would be completed. This meant people continued to be at potentially increased risk of harm from Legionella infections and fire.

The provider had not complied with the condition on their registration which required them to determine people’s individual capacity to consent to receive care and treatment from Masson House; and to request any necessary DoLS authorisations. This meant there was an increased risk that people may have been subject to unlawful care and treatment.

The provider had not complied with the condition on their registration which required them to send us written evidence that people’s care plans had been reviewed. The provider was also required to evidence how that review information had been used to calculate the numbers of suitably trained staff required to meet the care needs of people. This meant there was an increased risk that people would not receive safe and appropriate care.

The provider had not complied with the condition on their registration which required them to instruct a suitably qualified, and independent, nurse or pharmacist, to undertake oversight of medicines management at the care home. Additionally, the provider was required to send us copies of their monthly medicine quality audits but had not done so. This meant people continued to be at risk of harm from poorly managed medicines.

The provider had not complied with the condition on their registration which instructed the provider must not admit any new service users or readmit current service users to Masson House (if they should have been admitted into hospital for example), without the prior written permission of the Care Quality Commission. This meant we were not assured that people were able to be supported safely by the provider.

People were not supported to have maximum choice and control of their lives and the provider did not have suitable processes in place to ensure potential restrictions on people’s liberty were legally authorised and in their best interests; the policies, systems, and practice in the service did not take into account the requirements of the Mental Capacity Act 2005.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and/or who are autistic.

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

Rating at last inspection and update

The service was last rated Inadequate and was placed into special measures. The inspection report was published on the CQC website on 15 November 2023.

The previous inspection site visits had taken place on 23 and 24 August 2023, and 5 and 28 September 2023. The inspection report was completed, and a final copy shared with the provider, on 6 November 2023 before final publication on the CQC website.

As a result of the findings, from that previous inspection, CQC imposed urgent conditions on the provider’s registration on 3 October 2023.

Why we inspected

We undertook this targeted inspection, on 8 November 2023, to check whether the provider had complied with the urgent conditions we had imposed on their registration on 3 October 2023. A condition of registration places a limit or a restriction on what a provider can do. It may be linked to a location, regulated activity, service type, or specific activity.

In this case the imposed conditions restricted the admission, or readmission, of people to the care home; and a requirement that the provider send us satisfactory evidence of specified improvement actions having been completed, by the dates listed in the conditions notice.

We use targeted inspections to follow up on concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

The overall rating for the service has not changed following this targeted inspection and remains Inadequate.

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 Masson House on our website at www.cqc.org.uk.

Enforcement

We have identified ongoing breaches in relation to medicines management, health and safety, consent, staffing, and the management of the service.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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

The overall rating for this service remains ‘Inadequate’ and the service therefore continues to be in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

Masson House is a residential care home providing accommodation and personal care to up to 17 people. The service primarily provides support to older adults but can also support people over the age of 18. At the time of our inspection there were 16 people using the service. The care home is a large adapted domestic style building, which also has a purpose-built ground floor extension.

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

People were not always protected from potential abuse. The provider did not ensure all allegations of potential abuse were notified to the local authority or CQC. People were not always protected from the risk of potential harm from scalding, burns, or legionella infections. A suitable fire safety risk assessment was not in place.

People's medicines were not always safely managed, administered, or recorded consistently. Guidance for staff on people's individual medicines was not always accurate. People were not always supported by enough staff to meet their care needs.

People lived in a care home which was not always clean. There was an unpleasant urine odour present in several areas of the care home. The laundry room had evidence of black mould present which was a potential risk to people's health.

People had not been appropriately assessed to determine if they had the mental capacity to consent to live at the care home. People were effectively deprived of some aspects of their liberty, but the provider had not applied for authorisation from the relevant local authority. One person told us they did not want to live at Masson House but there was no evidence found that they were being supported to move to a different care home

People's care plans were not regularly reviewed and contained contradictory information about people's care and support needs. The provider was not able to evidence all staff had received the necessary training to enable them to care for people safely.

People had limited meal options offered to them and their preferences were not always identified and actioned. People were not always supported to access specialist advice from external healthcare professionals in a timely manner.

People told us they found the care home was sometimes cold and staff told us they did not have access to the heating controller to enable them to increase the temperature in the care home. People were not always supported to receive their 'as and when required' medicines in a timely manner, which had a particular impact on people who had been prescribed pain relief medicines.

Staff respected people's privacy when providing personal care support, and people were supported to dress appropriately to maintain their dignity. People were not often supported to take part in organised activities at the care home. People on end-of-life care did not always appear to be treated with compassion and empathy.

People were not supported to have maximum choice and control of their lives and the provider did not have suitable processes in place to ensure potential restrictions on people’s liberty were legally authorised and in their best interests; the policies, systems, and practice in the service did not take into account the requirements of the Mental Capacity Act 2005.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and/or who are autistic.

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 January 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.

You can see what action we have asked the provider to take at the end of this full report. The provider has told us they will take action to address the issues we found. Please see the Safe, Effective, Caring, Responsive, and Well Led sections of this full report.

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

Enforcement

We have identified breaches in relation to safety, safeguarding, medicines management, staffing, hygiene, consent, and the management of the service at this inspection.

We imposed conditions on the provider's registration with CQC, requiring the provider to send us assurances they had taken the required action to ensure people were safely supported. 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.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

This was the first comprehensive inspection carried out at Masson House.

Masson House is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates up to 17 people in one adapted building. On the day of our visit, there were 13 people using the service.

The service had a registered manager. 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.

The registered manager told us that they had recently implemented various new initiatives in relation to care planning, infection control and staffing. However, these needed time to become embedded in staff practice to demonstrate how effective they were at driving improvement at the service.

People were kept safe at the service. Staff had received training to enable them to recognise signs and symptoms of abuse and felt confident in how to report them. People had risk assessments in place to enable them to be as independent as they could be in a safe manner. The premises were appropriately maintained to support people to stay safe. Effective recruitment processes were in place and followed by the service and there were enough staff to meet people’s needs. People received their medicines safely and as prescribed.

Systems were in place to ensure the premises was kept clean and hygienic so that people were protected by the prevention and control of infection. There were arrangements in place for the service to make sure that action was taken and lessons learned when things went wrong, to improve safety across the service

People’s needs and choices were assessed and their care provided in line with best practice and met their diverse needs. There were sufficient numbers of staff, with the correct skill mix to support people with their care. Staff received an induction process when they first commenced work at the service and in addition also received on-going training to ensure they were able to provide care based on current practice when supporting people.

People received enough to eat and drink and staff gave support when required. People were supported by staff to use and access a wide variety of other services and social care professionals. The staff had a good knowledge of other services available to people and we saw these had been involved with supporting people using the service. People were supported to access health appointments when required, including opticians and doctors, to make sure they received continuing healthcare to meet their needs.

People’s diverse needs were met by the adaptation, design and decoration of premises and they were involved in decisions about the environment. Staff demonstrated their understanding of the Mental Capacity Act, 2005 (MCA) and they gained people's consent before providing personal care.

People developed positive relationships with the staff who were caring and treated people with respect, kindness and courtesy. The culture was open and honest and focused on each person as an individual. People were encouraged to make decisions about how their care was provided staff had a good understanding of people's needs and preferences.

People were listened to, their views were acknowledged and acted upon and care and support was delivered in the way that people chose and preferred. Care plans were person centred and reflected how people’s needs were to be met. Records showed that people and their relatives were involved in the care planning process and the on-going reviews of their care. They were supported to take part in activities which they wanted to do, within the service and the local community. There was a complaints procedure in place to enable people to raise complaints about the service.

People, relatives and staff were encouraged to provide feedback about the service and it was used to drive improvement. Staff felt they were well trained and supported by the registered manager. Staff attended regular meetings, which gave them an opportunity to share ideas, and exchange information about possible areas for improvements. The registered manager was aware of their responsibility to report events that occurred within the service to CQC and external agencies.