Halsey House

Updated 4 April 2023

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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 2 inspectors, a member of the CQC medicines team and 2 Experts 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

Halsey House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Halsey 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

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 February 2023 and ended on 15 March 2023. We visited the location’s service on 22, 23 and 27 February 2023.

What we did before 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

We observed and spoke with 9 people and 14 relatives. We spoke with 12 staff including the registered manager, head of operations, the deputy manager, staff from the catering department, staff from the quality team, staff from the health and safety department, nurses and care staff.

We reviewed a range of records. This included 8 people's care records and 12 people's medication records. We looked at 5 staff files in relation to recruitment, training and supervision. A variety of records relating to the management of the service including audits, policies and procedures were reviewed.

Updated 4 April 2023

About the service

Halsey House is a residential care home providing personal and nursing care to up to 89 people, some of who may be living with dementia. The dementia unit is a separate unit from the main building, which holds provision for people requiring nursing and residential care. At the time of our inspection there were 55 people using the service.

The care home is built over 3 floors. Many bedrooms have an ensuite shower and toilet. There are shared living areas on each floor. In addition, there is an enclosed garden which is wheelchair accessible and is available to people, their relatives and visitors.

People’s experience of using this service and what we found

Following the last inspection a review of the quality assurance systems had been conducted. However, these systems were not robust enough and had not addressed shortfalls identified within the records found at this inspection.

Since the last inspection the provider had completed a review of risk assessments and updated these to ensure they contained information to guide and direct staff in the delivery of person-centred care.

A process was in place to support the safe recruitment of staff. Staff completed an induction which equipped them to complete their role effectively.

Staffing levels were improving, and recruitment continued to take place at the service. Agency staff were used where required to maintain safe staffing levels.

People and their relatives told us they found the staff to be caring and passionate. Comments included, “The home is very honouring of those in the military. Staff provide care which is dignified and respectful of military service men, women and their families these actions bring a unique lift to the atmosphere. There is a warmth and caring feeling as soon as you walk in.” Other comments included, “There is real kindness amongst all staff here."

People, their relatives and staff provided positive feedback about the registered manager who they felt was approachable and addressed concerns raised in a timely manner.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 05 May 2020) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of some regulations. However, not enough improvements had been made in other areas and the provider was still in breach of the associated regulation.

The last rating for this service was requires improvement (published 05 May 2020). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We carried out an unannounced comprehensive inspection of this service on 13 March 2020 and breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and the management and governance of the service.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Halsey House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified repeat breaches in relation to the quality assurance processes in place at this inspection.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.