CQC report explained · a nursing home
What the CQC found at Sefton Hall
Rated Outstanding: inspectors found the home performing exceptionally well.
- Safe?
- Good
- Inspectors were assured about infection prevention and control, including visiting, admissions, protective equipment, testing, cleaning and outbreak management.
- Effective?
- Outstanding
- This area was not assessed in this targeted inspection.
- Caring?
- Outstanding
- This area was not assessed in this targeted inspection.
- Responsive?
- Outstanding
- This area was not assessed in this targeted inspection.
- Well-led?
- Outstanding
- This area was not assessed in this targeted inspection.
What inspectors found, February 2021
Inspected but not rated; inspectors were assured about the home's infection prevention and control arrangements.
This was an announced, targeted inspection on 15 January 2021. It looked at how the home was preventing and controlling Covid-19 infections.
Inspectors were assured that visitors were kept safe, social distancing and shielding rules were followed, and people were admitted safely. They were also assured about the use of protective equipment, testing, cleaning, outbreak planning and infection control policies.
The home helped people stay connected with relatives through drive-through visits, close-contact visits using lateral flow tests and activities within the grounds. It also created an isolation unit for people living with dementia who might find it difficult to isolate in their bedrooms.
The service was inspected but not rated. This report does not give an overall rating or ratings for the other four areas of care.
Keeping families connected
The home used several creative ways to help people maintain contact with relatives during the pandemic.
“People were supported to maintain relationships with their loved ones in creative ways.” from the report
Activities and social contact
Staff recreated a cancelled local carnival in the home's grounds and risk assessed activities to balance stimulation with safety.
“The staff made efforts to ensure people did not feel isolated by the lack of contact with family, friends and the community.” from the report
Isolation arrangements
The provider created a separate isolation unit with bedrooms and facilities for people who might find it difficult to isolate in their own rooms.
“The provider used funding available to create an 'isolation unit' within the building.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infection, including protective equipment, testing and outbreak planning.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Inspectors raised no specific concerns in this report.
- 01How have visiting arrangements changed since the January 2021 inspection?
- 02How are people and staff tested now, and what happens if someone tests positive?
- 03Is the isolation unit still available, and how would it be used for someone living with dementia?
- 04How will you help my relative keep in contact with family and avoid feeling isolated?
- 05What are the home's current ratings for Effective, Caring, Responsive and Well-led?
This was a targeted inspection of infection prevention and control, with the Safe question inspected but not rated; the other four questions were not assessed in this report. This explanation was written from the published report of 4 February 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.
What inspectors found, May 2020
Sefton Hall was rated Outstanding; inspectors found exceptional, personalised care, with a few records and checks needing improvement.
Inspectors visited on 26 and 27 February 2020. They looked at all five areas used by the CQC and spoke with people, relatives, staff and health professionals. They also observed care and checked records and systems.
The home was rated Outstanding overall. Effective, caring, responsive and well-led care were all rated Outstanding. Safe care was rated Good, which means people were safe and protected from avoidable harm, but it was not judged exceptional.
Inspectors found highly personalised care, strong staff training, good links with health professionals and many activities based on people's interests. Medicines, staffing, infection control and safeguarding were found to be safe.
Some improvements were made during the inspection. These included recording fire drills and training, checking hot water temperatures, and documenting the provider's visits more fully. The overall rating was unchanged from the previous inspection, published in August 2017.
Personalised care
Staff knew people very well and adapted care to their histories, interests, communication and changing needs. Inspectors found many examples of staff going beyond basic care to improve people's daily lives.
“People received outstanding person centred and individualised care from a motivated, skilled and exceptionally well led staff team.” from the report
Kind and respectful staff
People and relatives spoke very highly of the staff. Inspectors saw kindness, empathy and respect, including support for families during difficult changes in health.
“We saw numerous demonstrations by staff of exceptional kindness and empathy for people and their families.” from the report
Activities and independence
The home offered varied activities and adapted its spaces around the people living there. People were supported to keep hobbies, visit places and stay connected with the local community.
“The service was constantly being adapted to meet the needs of people well and staff encouraged people to maintain their independence and life skills.” from the report
Staff development
There had been significant investment in training, including practical dementia and clinical training. Inspectors found that learning had led to better outcomes for people.
“There had been a significant investment in staff training and development in best practice innovations which had resulted in improved outcomes for people, particularly those living with dementia.” from the report
Leadership and improvement
The management team promoted openness, learning and involvement. Staff, people and families were asked for their views, and complaints were used to make changes.
“Governance systems in place were robust and the registered manager had an in-depth understanding of how the home was performing and where improvements could be made.” from the report
Fire records and training
needs fixingInspectors found that records of fire drills and completion of fire drill training needed improvement. The manager said this had been addressed and the action plan was strengthened.
“The registered manager recognised the recording of fire drills and completion of fire drills training needed to improve” from the report
Hot water checks
needs fixingThe way hot water temperatures were recorded was not robust enough at first. Changes were made during the inspection.
“Changes were also made to the recording of hot water temperatures to make the checks more robust.” from the report
Documenting provider visits
minorThe provider understood how the home was performing, but inspectors said its regular visits should be documented more fully.
“The provider had a good understanding of how the service was performing, although they identified during the inspection their regular visits could be documented better.” from the report
- 01How have you kept the recording of fire drills and fire training up to date since the inspection?
- 02How are hot water temperatures checked and recorded now?
- 03How are provider visits documented, and how are any actions followed up?
- 04How would you tailor activities and daily routines to my relative's interests, history and communication needs?
- 05How do you involve families in care planning, complaints and decisions about end of life care?
This was a planned inspection based on the previous rating and covered all five CQC questions. This explanation was written from the published report of 16 May 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 Sefton Hall
3 rated inspections over 5 years: the service has improved, from Good to Outstanding.
- February 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- May 2020Outstandingstayed OutstandingSafe: GoodEffective: OutstandingCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- August 2017Outstandingup from GoodSafe: GoodEffective: OutstandingCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 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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