CQC report explained · a nursing home
What the CQC found at Horsfall House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Care records did not always show the support staff said they provided to keep people safe. Environmental risk records did not always show that identified risks had been fully reduced or controlled.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- Quality systems did not identify important gaps in records, recruitment and notifications. Some actions identified through fire and Legionella risk assessments had not been completed promptly.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found kind care and enough staff, but gaps in risk records, recruitment and quality checks increased safety risks.
This was an unannounced focused inspection on 30 November and 1 December 2022. Two inspectors and an Expert by Experience spoke with people, relatives, staff and a health care professional. They reviewed care records, medicines records, recruitment files, risk assessments, safety checks and quality audits.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found that care records and environmental safety records were not always complete. Recruitment checks were not always thorough, and the home had not told CQC when some Deprivation of Liberty Safeguards had been authorised.
There were also positive findings. Inspectors found enough staff, safe medicines management, safeguarding arrangements and staff who knew people well. People and relatives said they felt safe and well cared for. The provider was asked for an action plan, and CQC said it would monitor progress.
Enough staff
Inspectors found enough staff to meet people's care needs and keep them safe. Recent recruitment had also reduced the use of agency staff.
“There were enough staff employed to meet people's care needs and to keep people safe.” from the report
Medicines managed safely
Medicines records showed people received their medicines as prescribed. Staff had suitable training, including for end of life medicines and syringe drivers.
“People's medicines were managed safely, and relevant records showed people received their medicines as prescribed.” from the report
Kind and personal care
People, relatives and a health care professional described staff and managers as supportive. Staff showed that they knew people well as individuals.
“The registered manager promoted an open and inclusive culture, which included people who used the service, their relatives and the staff.” from the report
Safeguarding arrangements
Staff had safeguarding training and knew how to report concerns. Incidents were investigated and action was taken to protect people from harm.
“Incidents which involved the safeguarding of people were investigated and action taken to protect people from harm and reduce the likelihood of similar occurrences.” from the report
Incomplete risk records
seriousCare records did not always match the support staff said they provided. Records for fire and Legionella risks did not always show what had been done to reduce the risks.
“Environmental risks such as fire and legionella had been assessed. However, records were not available to show all the control measures the provider had taken to mitigate the risks identified.” from the report
Recruitment checks
seriousSome recruitment files did not contain interview details or complete employment histories. Gaps in employment had not always been explored.
“Recruitment folders did not include interview details to show how candidates had been considered suitable for a role.” from the report
Missing DoLS notifications
seriousThe home had not told CQC when some Deprivation of Liberty Safeguards had been authorised. The report says the required applications had been made to the local authority.
“CQC had not been informed as required when people's DoLS applications had been authorised.” from the report
Weak quality monitoring
seriousThe provider's audits had not identified the gaps found by inspectors. Some actions from fire and Legionella risk assessments had not been completed promptly.
“Quality assurance systems had not identified the gaps found during the inspection in relation to recruitment, notifications of Deprivation of Liberty Safeguards and health and safety records.” from the report
Bedroom door bolts
needs fixingInspectors were concerned that bolts on some bedroom doors in the dementia unit could be open to abuse. The provider was advised to seek reputable advice about other ways to protect people's belongings.
“We recommend the provider take advice, from a reputable source, about alternative ways of protecting people's belongings.” from the report
- 01What changes have you made to ensure each person's care record accurately describes the support needed for mobility, skin care and other risks?
- 02What evidence can you show that fire, Legionella and maintenance risks have been dealt with and checked?
- 03How do you now make sure every new staff member has complete employment history and a documented recruitment decision?
- 04Have all authorised Deprivation of Liberty Safeguards now been notified to CQC?
- 05What improvements have been made to the monthly audits and quality monitoring system since this inspection?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous rated inspection. This explanation was written from the published report of 12 January 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, December 2020
Minchinhampton Centre for the Elderly - Horsfall House: inspected but not rated; inspectors were assured about infection prevention and control during a coronavirus outbreak.
This was a targeted, announced inspection on 26 November 2020. It looked only at infection prevention and control because the home had experienced a coronavirus outbreak.
Inspectors found that the home had updated its policies, tested people and staff, used protective equipment, increased cleaning and separated the two nursing units. They were assured that the home was following safe infection prevention and control procedures.
The home supported people to isolate and keep in contact with relatives through calls and virtual visits. The inspection did not give an overall quality rating, and the service was recorded as inspected but not rated.
Up-to-date infection policies
The provider and manager updated infection control, visiting and staffing arrangements in response to national and local guidance.
“The registered manager and provider were proactive in updating policies and processes in line with national and local authority guidance.” from the report
Safer admissions
New admissions followed a negative COVID-19 test and were supported to self-isolate for up to 14 days.
“People were only admitted following a negative COVID-19 test result and supported to self-isolate for up to 14 days following admission, to reduce the risk of introducing infection.” from the report
Managing the outbreak
The home used testing, staff support and advice from public health and the local authority to manage the outbreak.
“The registered manager and staff had taken immediate action to manage an outbreak.” from the report
Keeping families informed
The home used several methods to keep families, the public and relevant agencies informed during the outbreak.
“An open and transparent approach was maintained throughout the outbreak to keep families, the public and appropriate agencies informed.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now?
- 02How are new admissions tested and supported to isolate?
- 03How are visits arranged when there is an infection risk, including visits at the end of life?
- 04How are people supported to stay socially engaged and in contact with relatives if visits are restricted?
- 05When were the other areas of care, such as caring, effective, responsive and well-led care, last fully inspected?
This was a targeted inspection of infection prevention and control practices only; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 16 December 2020 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 Horsfall House
4 rated inspections over 7 years: the service has slipped, from Outstanding to Requires improvement.
- January 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- September 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2017Requires improvementdown from OutstandingSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2015OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Outstanding
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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.
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