CQC report explained · a nursing home
What the CQC found at Mental Health Care Home with Nursing
Not yet rated: the CQC has not published a rated inspection for this home, which is usual for a new registration.
What inspectors found, January 2024
Malsis Hall is rated Requires Improvement; inspectors found kind staff, but risks, consent and management systems were not consistently safe.
Inspectors visited unannounced on 22 and 29 November 2023. They spoke with six people and 11 staff, and reviewed care records, medicines records, staff files and management documents. The inspection covered the care home part of the registration, not the separate mental health hospital.
There were improvements since the previous inspection, including safeguarding, staffing, staff training, privacy and incident reporting. However, risks were not always assessed or managed, medicines records and processes were not robust, and legal requirements about consent and restrictions were not always followed.
All five areas were rated Requires Improvement. Responsive had previously been rated Good but fell to Requires Improvement. The provider remained in breach of Regulations 11, 12 and 17, and CQC issued a warning notice about good governance.
Safeguarding
Safeguarding procedures were followed and concerns were reported to the relevant authorities. Staff understood how to report and escalate incidents.
“People were safeguarded from abuse and avoidable harm.” from the report
Staff skills and support
Staff had the skills and experience needed to provide care. Most staff were up to date with training and received supervision and appraisal.
“Staff had the skills, knowledge and experience to deliver effective care and support.” from the report
Privacy and independence
People's privacy and dignity were respected, and the home’s layout supported independence and life skills.
“People's privacy, dignity and independence were respected and promoted.” from the report
Handling complaints
Complaints were recorded, investigated and answered in a timely way. Most people said staff and managers listened to them.
“Complaints were logged, investigated and responded to in a timely manner.” from the report
Risks were not consistently managed
seriousSome health and safety risks did not have suitable care plans or monitoring. Staff were not always aware of important parts of people's plans.
“The provider had not always assessed risks to help ensure people were safe.” from the report
Medicines records and processes
seriousMedicines were not always supplied safely for leave and community activities. Information about when to give some as-required medicines was missing or not person-centred.
“Staff were not following the provider's medicine policy when people left the service to access community activities and overnight leave.” from the report
Consent and restrictions
seriousRestrictions on areas, kitchen utensils, cigarettes and alcohol were not always agreed legally or reviewed clearly. Some capacity assessments and best-interest decisions were incomplete.
“The provider had not followed the correct legal processes and consent had not been gained where required.” from the report
Care records were incomplete
needs fixingCare plans and reviews did not always contain enough detail about people's needs, progress or daily support. Food and fluid records were also inconsistent.
“Records relating to people's care and support were not sufficiently robust.” from the report
Activities were not always reliable
needs fixingSome activities were cancelled or did not happen as set out in care plans. The home did not consistently check whether activities met people's needs.
“Some people said staff did not always have time and they were cancelled.” from the report
- 01How are risks for each person assessed, updated after incidents and explained to every staff member supporting them?
- 02How are medicines supplied safely when people go out or take overnight leave, and how are as-required medicines explained in each person's care plan?
- 03How do you obtain consent or make best-interest decisions before restricting access to areas, kitchen utensils, cigarettes or alcohol?
- 04How often are restrictions reviewed, and how do you show that you are working to reduce them?
- 05How do you check that planned activities, food and drink monitoring, and daily support records are completed and reviewed?
This inspection covered the care home element of the registration and all five CQC questions; the separate independent mental health hospital at the same location was inspected and reported on separately. This explanation was written from the published report of 17 January 2024 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, April 2021
Malsis Hall is rated Requires Improvement; inspectors found some kind, person-centred care, but important gaps in safety, staffing, medicines and management.
This was the first inspection of the care home service. It was unannounced and took place over two days in February 2021. Inspectors spoke with people living there, relatives, staff and other professionals. They reviewed care records, medicines records, staff files and management records.
Inspectors found problems with safeguarding, risk assessments, incident reviews, staffing levels and medicines. Some people did not receive support quickly enough. Records were not always complete or up to date. The provider had also not followed the correct legal processes for some restrictions and consent decisions.
There were positive findings. Care plans included people's histories, likes and dislikes. Staff were often kind and people were supported to be independent. The home was clean and infection control measures were mostly effective. Activities and complaints handling were rated positively. The overall rating was Requires Improvement, with the same rating for Safe, Effective, Caring and Well-led. Responsive was rated Good.
Person-centred care plans
Care plans contained useful information about people's histories, likes and dislikes. Staff showed a good understanding of people's care and support needs.
“The care plans were person-centred to support staff in understanding people's likes, dislikes, background and history.” from the report
Kind staff interactions
Inspectors saw staff speaking to people respectfully and kindly. Most people spoken with were happy with the care they received.
“Staff were observed to engage positively with people using the service, speaking to them with respect and kindness.” from the report
Support for independence and activities
People were encouraged to develop daily living skills and take part in activities they enjoyed. The home also supported community involvement where possible.
“People were encouraged to be independent around their daily living skills and the service model and environment supported this.” from the report
Clean environment and infection controls
The environment was clean and hygienic. Inspectors found that most infection prevention measures were in place and effective.
“The provider had effective infection control measure in place and Personal Protective equipment available throughout the home.” from the report
Complaints were investigated
A complaints process was in place, and the manager investigated complaints thoroughly. People told inspectors they felt able to raise issues.
“A complaint process was in place and followed.” from the report
Safeguarding and risk management
seriousSafeguarding procedures were not consistently followed, and concerns were not always fully investigated or reported. Risk assessments and care plans did not always give staff enough guidance to prevent harm.
“Safeguarding concerns were not always thoroughly investigated by the provider.” from the report
Staffing levels
seriousThere were times when there were not enough staff available in the right buildings. Some people did not receive planned one-to-one support or timely help.
“Staffing levels were not always safe or sufficient to meet the needs of people using the service.” from the report
Medicines
seriousSome medicines were not available or were not given at the prescribed time. Stock counts did not always match, so inspectors could not be sure medicines were being given safely.
“Medicines were not always available in the service and administered as instructed.” from the report
Consent and privacy
seriousSome restrictions were used without clear evidence of consent, legal checks or regular reviews. Inspectors also found unclear arrangements for bedroom observation screens and CCTV.
“Some restrictions which impacted on people's human rights did not follow the correct legal processes or the providers own policy.” from the report
Management checks and records
needs fixingAudits did not find several of the problems identified by inspectors. Records were sometimes incomplete, inaccurate or out of date, and four incidents were not reported to CQC as required.
“Quality assurance arrangements, such as audits, were not always robust enough or effective in identifying the shortfalls found on inspection.” from the report
- 01What changes have been made to staffing levels and staff deployment so people receive planned one-to-one support and timely help?
- 02How are medicines now checked, counted and given at the correct times, including creams and time-specific medicines?
- 03How are safeguarding concerns, accidents and incidents investigated, recorded and reported to CQC and other agencies?
- 04How do you record consent and carry out Mental Capacity Act checks for restrictions such as phone monitoring, CCTV and bedroom observation screens?
- 05What evidence can you show that the action plan has been completed and that improvements have been sustained?
This was an unannounced inspection of the care home element and covered all five CQC questions; the separate mental health hospital service was reported on separately. This explanation was written from the published report of 24 April 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 Mental Health Care Home with Nursing
3 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Mental Health Care Home with Nursing →
- April 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Mental Health Care Home with Nursing →
- April 2021GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2019
Registered with the Care Quality Commission on 30 October 2019.
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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Most charge £1,010 to £1,290 a week. 27 can care for a couple. 12 years' experience on average.
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