CQC report explained · a residential care home
What the CQC found at Hallaton Manor Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2023
Rated Good overall; inspectors found kind, effective care, but safety records and some environmental checks needed improvement.
This was an unannounced focused inspection on 27 June 2023. Inspectors spoke with people, relatives and staff, observed care, reviewed care plans and medicines records, and checked recruitment, training and management records.
The overall rating was Good. People were supported by enough staff, received medicines safely, and were protected by safeguarding systems. Staff were described as kind, well trained and responsive to people's needs. The home also worked well with health and social care professionals.
The Safe rating was Requires Improvement. Some risk information was not detailed enough, fluid monitoring records were not completed consistently, and one shower room needed a deep clean. The Effective and Well-led ratings were Good. Inspectors found improvements since the previous inspection and said the home was no longer in breach of regulations.
Safeguarding
Safeguarding concerns were escalated and managed promptly. Staff knew how to raise concerns and incidents were reviewed to improve practice.
“The registered manager escalated safeguarding concerns and liaised promptly with external agencies to ensure lessons could be learned to improve safeguarding practices.” from the report
Medicines
Medicines were ordered, stored, administered and disposed of safely. Staff were trained and their competence was checked.
“Medicines were ordered, stored, administered and disposed of safely.” from the report
Staffing and training
Inspectors found enough staff to keep people safe. Recruitment checks were completed and staff training was kept up to date.
“There were enough staff to ensure people received safe care.” from the report
Respect and choice
Staff asked for consent, respected people's decisions and followed mental capacity and best-interest processes where needed.
“We observed staff seeking consent before assisting people and respecting people's decisions and choices.” from the report
Open management
People, relatives and staff said they could speak openly with the manager. The culture was described as person-centred and empowering.
“The registered manager and provider had developed an open and honest culture.” from the report
Incomplete risk information
needs fixingSome care plans did not explain clearly enough how staff should recognise and respond to distress or other known risks. This could make consistent support harder, even though staff were seen providing safe support.
“Risks associated with people's care had been identified but some care records required further development to provide detailed information around minimising risks occurring.” from the report
Fluid monitoring records
needs fixingRecords of people's fluid intake were not always completed consistently when people were at risk of dehydration. Inspectors saw people being supported to drink, but this was not clearly recorded.
“Core safety information, such as fluid intakes where people were at risk of dehydration, were not consistently recorded.” from the report
Cleanliness and maintenance
needs fixingOne shower room was dirty and needed a deep clean. Inspectors also found a window restrictor and a cracked window that needed action, which the manager addressed during or after the visit.
“We found one shower room which was dirty and required a deep clean to remove a build up of dirt and debris.” from the report
Checks did not identify all issues
minorThe home's audits had not identified the problems inspectors found. The manager addressed them quickly, but this suggests checks were not yet fully effective.
“Audits had not identified the issues we found, though these were quickly addressed by the registered manager.” from the report
- 01How are you now recording fluid intake for people at risk of dehydration, and how do you check that records are complete?
- 02Have all behaviour support plans been updated to describe early signs of anxiety, crisis behaviours and the right staff response?
- 03What checks now make sure shower rooms and other areas are clean and free from maintenance risks?
- 04How do you check that personal emergency evacuation plans remain accurate when people's physical needs change?
- 05How are you monitoring whether the improvements to care records are now consistently followed by all staff?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected during this visit and the overall rating used previous ratings for questions not inspected. This explanation was written from the published report of 25 August 2023 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, June 2021
Rated Requires Improvement; inspectors found kind and consistent care, but gaps in risk records, consent processes, training and management oversight.
This was an unannounced focused inspection on 13 April 2021. Inspectors looked only at Safe, Effective and Well-led. They spoke with people, relatives and staff, observed care, and checked care plans, medicines, recruitment, training and management records.
The home had enough staff and people were supported by staff who knew them well. Medicines were managed safely, infection controls were mostly in place, and people received support with food, drink and healthcare.
However, risk assessments did not always give staff enough detail to keep people safe. Staff training and recruitment records were not always adequate. The home did not consistently follow legal requirements about consent and best-interest decisions for people who lacked capacity.
The overall rating fell from Good to Requires Improvement. Caring and Responsive were not inspected during this visit, so their previous ratings were carried forward.
Enough staff
Inspectors found sufficient staff on duty to meet people's needs. People and staff also said staffing levels were adequate.
“We found sufficient numbers of staff were deployed on the day of inspection to meet people's needs.” from the report
Medicines
Medicines were stored securely and records were described as robust. Staff had training and competency checks.
“Medicines were stored securely and supported by robust records.” from the report
Food and drink
People were supported to eat and drink enough, with their preferences and health needs taken into account.
“People were supported to have sufficient amounts to eat and drink and encouraged to maintain a balanced diet.” from the report
Staff knew people well
Staff were described as kind, knowledgeable and familiar with people's individual needs. The new manager was seen as approachable and responsive.
“Staff demonstrated they know people well and were enthusiastic about improvements and changes.” from the report
Incomplete risk records
seriousSome risk assessments did not explain clearly how staff should support transfers, monitor health conditions or respond to distressed behaviour. This meant records did not always reflect what staff knew about people's needs.
“Risk assessments did not always include information on the measures staff needed to take to keep people safe.” from the report
Consent and best-interest decisions
seriousThe home did not consistently follow the Mental Capacity Act for people who could not make particular decisions themselves. Inspectors found that best-interest processes were not always followed and some DoLS applications were late.
“Best interest processes had not been followed. This was a breach of Regulation 11 (need for Consent) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Staff training and recruitment checks
seriousThe in-house trainer's qualifications had lapsed, so training already completed was not reliable. Recruitment files did not always show that employment gaps, identity, right to work and references had been properly checked.
“The provider had failed to ensure staff received appropriate training and induction to ensure they had the relevant skills to support people appropriately.” from the report
Premises and infection control
needs fixingSome flooring and toilets needed repair or improvement, and inspectors saw three people using the same hoist sling for a standing aid. The manager said the sling issue would be addressed after the inspection.
“We observed three people were supported to use standing aid equipment using the same hoist sling.” from the report
Weak improvement oversight
needs fixingAudits had not found several of the problems identified by inspectors. There was no action plan setting out responsibilities and timescales for improvements.
“There was no action plan detailing how and when improvements would be made and sustained.” from the report
- 01What has been done to ensure every person who lacks capacity has a current mental capacity assessment, best-interest decision and timely DoLS application where needed?
- 02How have risk assessments been updated for moving, handling, health monitoring and distressed behaviour?
- 03Which staff training has been completed since the inspection, and how are trainer qualifications and staff competency now checked?
- 04What repairs and privacy improvements have been completed, including flooring, the communal toilet and en-suite doors or curtains?
- 05Where is the formal improvement plan, and who is responsible for each action and its completion date?
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 30 June 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 Hallaton Manor Limited
5 rated inspections over 7 years: the service has held its Good rating throughout.
- August 2023Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 9 December 2010.
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.
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