Malsis Hall - Mental Health Care Home with Nursing

Malsis Hall Mental Health Rehabilitation Service is an independent mental health hospital and care home with nursing based in Glusburn, North Yorkshire.

This report refers to the care home element of the registration only. The independent mental health hospital is inspected and reported on separately, but falls under the same provider and location address.

The service supports up to a maximum of 19 younger adults with mental health needs; there are three named units across four separate buildings. Worth Suite has six en-suite bedrooms with a shared communal kitchen and one large self-contained apartment. Pullen Cottages is two attached buildings with four self-contained apartments in each building. Frost House has four individual self-contained apartments. At the time of the inspection there were 16 people living in the service.

People’s experience of the service and what we found:

Risks to people’s health and safety were not consistently assessed and mitigated and staff were not always clear about risk management plans. Whilst some improvements had been made to medicines management since the last inspection, the service was failing to ensure there were adequate and robust systems in place to ensure policies were followed and ensure detailed care records were in place for staff to support people with their medicines.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

Safeguarding procedures were in place and were followed to help keep people safe. Incidents and accidents were recorded and analysed although post-incident debriefs did not always take place.

Staffing levels were sufficient within the service although there had been instances of staff not being appropriately deployed. Safe recruitment procedures were in place.

Staff received a range of training, supervision and appraisal. Staff said they felt well supported by the management team. People’s nutritional needs were assessed although records of people’s food intake were not consistently completed.

Staff were kind and caring, but restrictions to people were not always robustly documented to show their human rights had been upheld. In most cases, people were involved in decisions relating to their care.

Care plans did not always contain detailed and person-centred information about people's needs and the care they received. Reviews were not consistently completed People had access to a range of activities although the monitoring of these needed improving.

Systems to assess, monitor and improve the service were not suitably robust. The provider needed to ensure systems were operated to ensure consistent compliance with our regulations. People, staff and other stakeholders were regularly consulted to their views on 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 and update

The last rating for this service was Requires Improvement in April 2021. We found the provider was in breach of 6 regulations relating to Failure to Notify CQC of incidents, failure to provide safe Care and treatment, staffing, safeguarding, consent and good governance.

At this inspection some improvements had been made, but the provider remained in breach of regulations relating to safe care and treatment, consent and good governance.

Why we inspected

The inspection was prompted in part due to concerns received about safeguarding, and staffing, but also to follow up on breaches of regulation identified at the last inspection in 2021. A decision was made for us to inspect and examine those risks.

Enforcement

We have identified breaches in relation to safe care and treatment, consent and good governance.

Please see the action we have told the provider to take at the end of this report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow Up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Malsis Hall Mental Health Rehabilitation Service is an independent mental health hospital and care home based in Glusburn, North Yorkshire. The service is based in a Grade II listed former country house and has three other buildings on site.

The service is registered as both a care home without nursing and care home with nursing. The service supports up to a maximum of 19 younger adults both male and female; there are three named units across four separate buildings. The service was registered to provide Regulated Activities associated with a care home and care home with nursing in October 2019.

Worth Suite has six en-suite bedrooms with a shared communal kitchen and one large self-contained apartment. This is registered as a care home with nursing.

Pullen Cottages is two attached buildings with four self-contained apartments in each building. There is one shared communal area and garden. This is registered as a care home with nursing.

Frost House has four individual self-contained apartments and is registered as a care home without nursing.

The service also provides four long stay mental health rehabilitation wards, for working age adults, based in the Shelton Hospital. Each ward has eight en-suite rooms. The service registered to provide Regulated Activities associated with a mental health hospital in March 2020. The service has not previously been inspected and as such has been unrated until this first inspection.

This report refers to the care home element of the registration only. The hospital inspection has been reported on in a separate inspection report which is also linked to this provider.

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

Policies and procedures around safeguarding were not effectively embedded in the service. This put people at risk of avoidable harm. Accidents and incidents were not thoroughly reviewed so that lessons could be learnt to improve the quality of the service. Risk assessments and care plans were not always in place or did not provide enough detail for staff to appropriately support people.

Staffing levels did not always meet the needs of people, taking into consideration the environment and layout of the buildings. This led to people not being able get support from staff in a timely manner. Medicines were not always managed safely.

Peoples cultural, religious and ethical needs where not always identified or support evidenced. People were not always supported to have maximum choice and control of their lives, and staff did not support them in the least restrictive way possible and in their best interests; the providers policies and systems in the service did not support this practice.

The providers quality assurance processes and audits had failed to identify the shortfalls we found during this inspection. The provider did not always share significant information with CQC where there was a legal obligation to do so.

The care plans were person-centred to support staff in understanding people’s likes, dislikes, background and history. Staff demonstrated a good understanding of people’s care and support needs and were caring in their interactions. People were encouraged and supported to be independent in their daily living and the model of the service supported this.

Infection prevention and control measures were in place and effective. The environment was clean and hygienic.

The provider and registered manager were responsive to the concerns and shortfalls we identified at the inspection. They took immediate action to address concerns and demonstrated their commitment to improving 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

This service was registered with us on 30 October 2019 and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about infection prevention control, staffing issues and general concerns about the management of the service. A decision was made, in accordance with our inspection methodology, for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, and well-led sections of this full report. There were no improvements needed in the way the service responded to people’s needs.

You can see what action we have asked the provider to take at the end of this full report.

The provider took action to mitigate any immediate risk identified on inspection. Further time was needed to ensure these improvements were effectively embedded within the service and sustained.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to person-centred care, safe care and treatment, safeguarding, good governance, consent and staffing at this inspection.

We recognised that the provider had failed to notify CQC of incidents. This was a breach of regulation. Full information about CQC’s regulatory response to this is added to reports after any enforcement activity is taken and concluded, this may include any representations and appeals against any actions deemed necessary.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.