23 September 2023
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 Care Act 2014.
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.
The inspection visit was completed by 3 inspectors, 1 specialist advisor and 1 Expert by Experience. An Expert by Experience is someone who has experience of using this type of service.
Service and service type
Gainsborough Hall is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Gainsborough Hall is a care home with nursing care. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.
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 not a registered manager in post. The director of operations told us a new manager would be appointed shortly and would apply to become registered with us.
Notice of inspection
This inspection visit was unannounced.
What we did before inspection
We reviewed the information we held about the service, such as feedback from people and their relatives, statutory notifications, as well as any information shared with us by the local authority, commissioners and Healthwatch. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 2 people and 8 relatives about the service provided to get their experiences about the quality of care. We spoke with 5 members of care staff, 2 nursing staff, a chef, 2 deputy managers, a company director and a director of operations.
We reviewed a range of records. This included examples of 5 people’s care records, including records to support and promote oral health. We looked at records that related to the management and quality assurance of the service and records of staff training.
23 September 2023
About the service
Gainsborough Hall is registered to provide accommodation, nursing and personal care for up to 74 people, including younger people, older people, people living with dementia and people with a physical disability.
At the time of our inspection visit there were 33 people living at the home. Care is provided across 3 floors that include a residential and nursing unit. A communal lounge and dining area are located on each floor. People’s bedrooms are ensuite and there are further communal bathroom facilities located on each floor.
People's experience of using this service and what we found
Relatives felt involved in care planning for their family member. Relatives told us their family members choices were accommodated and considered.
Relatives told us staff knew what to do and staff were trained which gave them confidence their relatives received the right level of support. Training refreshers were held to make sure staff received training to maintain staff skill and knowledge.
People and relatives were pleased with their meal choices, and they could have additional choices if requested. People received their food and fluids in line with personal preferences. People who were at risk of weight loss were regularly checked by staff to ensure any further support was provided to help maintain their health and welfare.
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.
The management team and provider completed regular audits and checks, including clinical and checks that supported a quality service.
There was no registered manager at the time of our visit but the senior management team remained consistent and they supported temporary managers at the home. A new manager was being appointed and would make an application to be registered with us.
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 last rating for this service was good (published 07 October 2022).
Why we inspected
The inspection was prompted in part due to concerns received about a lack of important health information being known by and available to staff. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of effective and well-led only.
We found no evidence during this inspection that people were at risk of harm from this concern.
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. In Safe, we did not look at the entire key question, only the part of the key question related to infection prevention and control. This does not change the rating from the previous inspection.
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 stayed the same. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Gainsborough Hall on our website at www.cqc.org.uk.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.