Archived: West Hallam Care Home

Updated 13 January 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 25 and 27 October 2016. The first day of our inspection visit was unannounced. The inspection visit on the first day was carried out by one inspector, a specialist advisor in older person’s nursing care, and an expert-by-experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The second day of the inspection visit was carried out by one inspector.

Before the inspection, we asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well, and improvements they plan to make. This was returned to us by the service.

Before our inspection visit we reviewed the information we held about the service including notifications the provider sent us. A notification is information about important events which the service is required to send us by law. For example, notifications of serious injuries or allegations of abuse. We spoke with the local authority and health commissioning teams, and Healthwatch Derbyshire, who are an independent organisation that represents people using health and social care services. Commissioners are people who work to find appropriate care and support services which are paid for by the local authority or by a health clinical commissioning group.

During the inspection we spoke with nine people who used the service, and four relatives. We also received feedback from four health and social care professionals. We spoke with three care staff, the activity coordinator, and the registered manager. We also spoke with the provider’s area manager, dementia care manager, and one of the partners in the provider’s business. We looked at a range of records related to how the service was managed. These included six people’s care records (including their medicine administration records), three staff recruitment and training files, and the provider’s quality auditing system.

Updated 13 January 2017

This inspection took place on 25 and 27 October 2016. The service was last inspected on 30 October and 4 November 2015 when they were rated as Requires Improvement, and we found a breach of Regulation 12 and a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. On this inspection, we found that improvements had been made in respect of the breach of Regulation 12. However, evidence demonstrated there was a continued breach of Regulation 17. The first day of our inspection visit was unannounced.

West Hallam Care Home is a 31 bed residential home. It has two parts: the main building provides residential care for 19 people, and the extra care unit (within the main building) provides specialist residential care for 12 people living with dementia. At the time of our inspection, there were 22 people living in the service. 10 people were living in the extra care unit and 12 people were in the residential area of the home.

The service had a registered manager at the time of our inspection visit. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had systems to monitor and review all aspects of the service, and these were undertaken regularly. However, the systems did not always identify where areas of care needed to be improved. This meant the provider was not always able to identify areas for improvement, and to make changes to improve the quality of the service for people.

People’s care needs were assessed and recorded and risks identified. However, risk assessments and care plans did not consistently identify steps staff should take to reduce the risk of avoidable harm, and were not always up to date.

The systems for managing medicines was not consistently safe. The provider had not taken steps to ensure that people had medicines available when needed, or that medicines were given in accordance with prescribing instructions.

People were happy with staff who provided their personal care. They were cared for by sufficient numbers of staff who were suitably skilled, experienced and knowledgeable about people’s needs.

The provider took steps to ensure checks were undertaken to ensure that potential staff were suitable to work with people needing care. Staff received supervision and had checks on their knowledge and skills. They also received an induction and training in a range of skills the provider felt necessary to meet the needs of people at the service.

Staff worked in cooperation with health and social care professionals to ensure people received appropriate healthcare and treatment in a timely manner.

Appropriate arrangements were in place to assess whether people were able to consent to their care. The provider met the legal requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DOLS).

People felt care for by staff who treated them with dignity and respect. People were supported to be involved in their care planning and delivery. The support people received was tailored to meet their individual needs, wishes and aspirations. People, their relatives, and staff felt able to raise concerns or suggestions in relation to the quality of care. The provider had a complaints procedure to ensure that issues with quality of care were addressed.

You can see what action we told the provider to take at the back of the full report.