Background to this inspection
Updated
20 August 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
Inspection team
This inspection was undertaken by three inspectors and one 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.
Service and service type
Halvergate House is a ‘care home’. People in care homes receive accommodation and/or nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Halvergate House is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
Inspection activity started on 22 June 2022 and ended on 6 July 2022 when final inspection feedback was provided. We visited the service on 22 June 2022.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
During the inspection we spoke with five staff, including the registered manager, deputy manager, two care staff and one nurse. We also spoke to three people using the service and six family members. We reviewed four care records, three medicine administration records (MAR) and observed medication round. We looked at two staff files in relation to recruitment. We also reviewed other records, including policies and procedures, audits relating to the safety and quality of the service.
Updated
20 August 2022
About the service
Halvergate House is a nursing home providing personal and nursing care for up to 50. The service provides support to older people and younger adults some who might be living with dementia, physical disabilities, learning disabilities or autistic spectrum disorder. At the time of our inspection there were 36 people using the service.
Halvergate House is an adapted building ,split across two floors with access via a lift or a staircase. The service benefits from courtyard and gardens for people to use. Ground floor rooms benefit from patio doors out into the garden and all rooms have ensuite toilets.
People’s experience of using this service and what we found
The quality assurance monitoring systems in place were not effective in maintaining and improving the quality of care provided to people.
People’s documents were not personalised and not all information had been recorded effectively.
The care environment was visibly clean, although some areas of the home were tired and require modernisation, the service have a development plan in place for improvement of the environment.
Staff received mandatory training; however, they lacked training to meet people’s specific needs.
People said they felt safe at the service. One person told us, “Oh yes perfectly safe. Everybody is nice and friendly.”
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
The provider and operations manager had implemented an action plan prior to our inspection to make improvements to the service. We saw this action plan was beginning to take effect but would take time to be fully embedded at the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 21 December 2021).
Why we inspected
We received concerns in relation to the safe care and treatment of people living in the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Halvergate House on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to safe care and treatment, good governance and staffing at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.