CQC report explained · a residential care home
What the CQC found at Goole Hall
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found gaps in medicines instructions, records for as-needed pain relief and medicine protocols. Staffing, risk management and infection control had improved, but some safeguarding and recruitment records were not complete.
- Effective?
- Requires improvement
- People were supported with food, drink and healthcare, and staff had suitable training. However, some fluid records, care plans and records of healthcare professional involvement were incomplete or inconsistent.
- Caring?
- Good
- This question was not inspected during this focused visit. Inspectors observed positive interactions and described a caring culture.
- Responsive?
- Good
- This question was not inspected during this focused visit. The report says people took part in meaningful activities and could choose where to spend their time.
- Well-led?
- Requires improvement
- Quality systems had been reviewed and updated, but they had not identified all the problems found. Records were not always accurate and feedback had not consistently been sought from people and relatives.
What inspectors found, June 2022
Goole Hall is rated Requires Improvement; inspectors found medicines records and quality checks were not reliable, although some safety and care improvements had been made.
This was an unannounced focused inspection on 9 and 24 March 2022. Inspectors checked whether the home had acted on problems found at the previous inspection. They spoke with people, relatives, staff and managers, and checked care files, medicines records, staff files and other records.
The home remained rated Requires Improvement. Safe, Effective and Well-led were all rated Requires Improvement. Inspectors found that medicines records did not always give staff enough information to administer medicines safely. Quality checks had improved but had not found all the problems with medicines, recruitment and safeguarding records.
There were also improvements. Staffing levels were considered safe, risks were generally identified and managed, and the home was no longer in breach of earlier requirements about infection control, consent, staffing and some dietary records. Inspectors found kind interactions, meaningful activities and positive feedback about the new manager.
Safe staffing
Inspectors found that staffing numbers were suitable for people's needs and that staff supported people promptly. Agency staff were given an induction about safety procedures.
“Staffing numbers were appropriate to meet people's needs. We observed staff supporting people in a timely manner.” from the report
Respectful care and choices
Staff sought consent, respected refusals and offered support again later. Where people lacked capacity, decisions were made in their best interests with family involvement.
“Staff sought people's consent and respected people's right to refuse support.” from the report
Activities and relationships
People had access to group and individual activities, including exercises, quizzes and knitting. The report also describes positive interactions between staff and people.
“A range of activities were held to promote people's wellbeing.” from the report
Medicines records
seriousSome handwritten records did not include complete instructions. Records for as-needed pain relief and other medicines were incomplete, so inspectors could not be sure medicines were always given as prescribed.
“We could not always be assured that people received their medicines as directed as handwritten medicine records did not always include full instructions how to administer medicines.” from the report
Quality checks
seriousThe home's monitoring systems had improved but had not found problems with medicines, recruitment and safeguarding records. Accident information was also not always correctly analysed.
“Although the issues we found with medicines, recruitment records and safeguarding records had not always been identified or addressed.” from the report
Incomplete care information
needs fixingSome care plans waiting for review did not contain all the information staff needed. Some fluid records did not show that people had drunk enough to stay well.
“Though we found some fluid records did not always show people had drank enough to keep them well.” from the report
Safeguarding and recruitment records
needs fixingThree safeguarding concerns had been referred but were not recorded in the home's records. Employment gaps were not always explored and interview records did not show how suitability had been assessed.
“We found three concerns had been appropriately referred but were not recorded, which meant it was difficult for the provider to monitor and review safeguarding issues.” from the report
- 01What has been changed so medicine records always contain full administration instructions?
- 02How are as-needed pain medicines recorded, including when they are offered and whether they helped?
- 03How do managers now check that safeguarding concerns, recruitment records and care records are complete?
- 04How are fluid records reviewed when someone is at risk of dehydration?
- 05What progress has been made with the CQC action plan, and when will the manager be registered?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the other ratings used in the overall rating carried over from the previous inspection. This explanation was written from the published report of 15 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2021
Rated Requires Improvement, with an Inadequate well-led rating; inspectors found serious problems with safety, medicines, records, staffing and management.
This was a focused inspection following concerns about medicines, staffing and whether people's care needs were being met. Inspectors visited on 25 February and 1 March 2021, then gathered more evidence by telephone and email. They spoke with people, relatives and staff, and checked care, medicines, staffing and management records.
People were not always protected from avoidable harm. Care plans and risk assessments lacked important information. Medicines were not managed safely, COVID-19 safety guidance was not always followed, and some fire doors were not closing properly. Staff told inspectors there were not enough staff, and some recruitment checks were incomplete.
The service did not always provide effective care. Staff training and supervision were incomplete, mental capacity and deprivation of liberty requirements were not always followed, and records about food, drink and healthcare were unreliable. There were no activities provided, and people were not always supported to move freely or receive enough interaction.
The overall rating fell from Good at the previous inspection to Requires Improvement. Safe and Effective were rated Requires Improvement, while Well-led was rated Inadequate. Caring and Responsive were not inspected, so their previous ratings carried over into the overall rating.
People felt safe
The people inspectors spoke with said they felt safe and described staff positively, despite the wider safety concerns found.
“I am happy here, the staff are good, and I feel safe with them.” from the report
Food was enjoyed
People told inspectors they enjoyed the food. However, records about fluid intake and some dietary needs were not reliable.
“We always get good food.” from the report
Family communication
One relative said the home kept them informed during COVID-19 restrictions. The provider also said it supported video calls, telephone calls and window visits.
“The staff keep us informed how they are.” from the report
Links with health services
The home worked with organisations such as local district nurses, although inspectors said partnership working needed further development.
“The service worked with key organisations such as the local district nurses.” from the report
Unsafe medicines
seriousStaff responsible for medicines were not sufficiently knowledgeable or competent. People did not always receive medicines at the prescribed times, and supporting records were missing.
“Medicines were not managed safely.” from the report
Poor care and risk records
seriousCare plans and risk assessments were not personalised or detailed enough to guide safe care. Daily records and monitoring charts were also inconsistent.
“People were at risk of harm due to poor information recorded in care plans.” from the report
Infection control failures
seriousCOVID-19 testing was delayed, personal protective equipment procedures were not always followed, and risks linked to people attending community settings had not been properly assessed.
“People did not receive COVID-19 tests in line with Government guidance in February 2021.” from the report
Insufficient training and support
seriousThere were significant gaps in training, including fire safety and care for pressure areas and diabetes. Supervision and induction were inconsistent.
“Staff were not suitably trained or supported in their role.” from the report
People's legal rights
seriousThe home did not always follow the Mental Capacity Act. Some applications for deprivation of liberty safeguards were missing or had expired.
“The service had not always followed the principles of the MCA.” from the report
Weak management oversight
seriousQuality audits and action plans did not reliably identify or resolve problems. Staff morale was low and staff said they were not listened to or supported.
“The principles of good quality assurance were not understood; audits were not actually auditing, and action plans were not followed up or structured to allow effective monitoring.” from the report
- 01What has been done to make medicines administration safe, including staff competency checks and records for creams and as-required medicines?
- 02Have every resident's care plan and risk assessment been reviewed and personalised, and how are changes checked?
- 03What training and supervision have staff completed, especially fire safety, medicines, pressure area care and diabetes management?
- 04How are mental capacity assessments and deprivation of liberty applications now monitored so that restrictions are lawful?
- 05What evidence can you show that the warning notice and the action plan have been addressed?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 10 July 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Goole Hall
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- June 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- September 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Requires improvement
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015Inspected but not ratedSafe: Requires improvementWell-led: Requires improvement
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
16 live-in carers within about an hour of East Riding of Yorkshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,420 a week. 14 can care for a couple. 7 years' experience on average.
“She was always 'just present enough': attentive, available, kind and engaging, but without ever over-stepping any boundary”
“What truly stands out is how mindful and attentive she is to all of my medical needs, always going above and beyond to ensure I’m comfortable and well cared for.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.