• Mental Health
  • Independent mental health service

Malsis Hall - Mental Health Rehabilitation Service

Overall: Requires improvement read more about inspection ratings

Malsis Hall, Malsis Drive, Glusburn, Keighley, BD20 8FH (01535) 286240

Provided and run by:
Malsis Hall Limited

All Inspections

10 February 2021

During a routine inspection

About the service

Malsis Hall Mental Health Rehabilitation Service is an independent mental health hospital and care home based in Glusburn, North Yorkshire. The service is based in a Grade II listed former country house and has three other buildings on site.

The service is registered as both a care home without nursing and care home with nursing. The service supports up to a maximum of 19 younger adults both male and female; there are three named units across four separate buildings. The service was registered to provide Regulated Activities associated with a care home and care home with nursing in October 2019.

Worth Suite has six en-suite bedrooms with a shared communal kitchen and one large self-contained apartment. This is registered as a care home with nursing.

Pullen Cottages is two attached buildings with four self-contained apartments in each building. There is one shared communal area and garden. This is registered as a care home with nursing.

Frost House has four individual self-contained apartments and is registered as a care home without nursing.

The service also provides four long stay mental health rehabilitation wards, for working age adults, based in the Shelton Hospital. Each ward has eight en-suite rooms. The service registered to provide Regulated Activities associated with a mental health hospital in March 2020. The service has not previously been inspected and as such has been unrated until this first inspection.

This report refers to the care home element of the registration only. The hospital inspection has been reported on in a separate inspection report which is also linked to this provider.

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

Policies and procedures around safeguarding were not effectively embedded in the service. This put people at risk of avoidable harm. Accidents and incidents were not thoroughly reviewed so that lessons could be learnt to improve the quality of the service. Risk assessments and care plans were not always in place or did not provide enough detail for staff to appropriately support people.

Staffing levels did not always meet the needs of people, taking into consideration the environment and layout of the buildings. This led to people not being able get support from staff in a timely manner. Medicines were not always managed safely.

Peoples cultural, religious and ethical needs where not always identified or support evidenced. People were not always supported to have maximum choice and control of their lives, and staff did not support them in the least restrictive way possible and in their best interests; the providers policies and systems in the service did not support this practice.

The providers quality assurance processes and audits had failed to identify the shortfalls we found during this inspection. The provider did not always share significant information with CQC where there was a legal obligation to do so.

The care plans were person-centred to support staff in understanding people’s likes, dislikes, background and history. Staff demonstrated a good understanding of people’s care and support needs and were caring in their interactions. People were encouraged and supported to be independent in their daily living and the model of the service supported this.

Infection prevention and control measures were in place and effective. The environment was clean and hygienic.

The provider and registered manager were responsive to the concerns and shortfalls we identified at the inspection. They took immediate action to address concerns and demonstrated their commitment to improving the service.

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 30 October 2019 and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about infection prevention control, staffing issues and general concerns about the management of the service. A decision was made, in accordance with our inspection methodology, for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, and well-led sections of this full report. There were no improvements needed in the way the service responded to people’s needs.

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

The provider took action to mitigate any immediate risk identified on inspection. Further time was needed to ensure these improvements were effectively embedded within the service and sustained.


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.

We have identified breaches in relation to person-centred care, safe care and treatment, safeguarding, good governance, consent and staffing at this inspection.

We recognised that the provider had failed to notify CQC of incidents. This was a breach of regulation. Full information about CQC’s regulatory response to this is added to reports after any enforcement activity is taken and concluded, this may include any representations and appeals against any actions deemed necessary.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

10 February 2021

During a routine inspection

  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. However, care plans were nurse led and often written using clinical language that did not reflect the patient voice. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The service worked to a recognised model of mental health rehabilitation. It was well led and the governance processes ensured that ward procedures ran smoothly.


  • The service did not always provide safe care. At the time of our inspection none of the registered nurses were trained in immediate life support and the provider did not offer this training or have the equipment that would be needed to carry out immediate life support. We spoke to the provider about this at our inspection feedback. Following on from this we were informed that this training had been booked for all registered nurses. However, this had not yet taken place. The wards had enough nurses and doctors, although this was not always clear from the staffing rotas as they did not indicate which ward staff were allocated to for the the shift.The ward environments were clean. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • We found one incident where the provider failed to notify CQC of a police incident which they were legally obliged to do so. This meant that CQC was not always aware of incidents that had occurred in the service. We found that the incident report log had gaps in some areas.