Malsis Hall - Mental Health Care Home with Nursing

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the ways people’s medicines were managed safely.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders at the service had a culture of openness, honesty and continual development. Leaders had a clear plan of improvement to learn from incidents, accidents and events to make sure people were protected from avoidable harm. The provider analysed accidents and incidents in a clear way to highlight areas of improvement and learning which was shared with staff. A leader at the service told us, “We meet every month and review what has been happening at Malsis Hall. This includes accidents and incidents. We analyse what has happened and if there is any learning needed.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had positive working relationships with partners. Staff and leaders at the service worked closely with the police, GP, district nurses and mental health professionals to make sure people had access to the care they needed. One visiting professional told us, “We had some concerns about Malsis Hall in 2024, but following a meeting with the managers, things are now much better.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately with involved professionals.

People were protected from the risk of abuse or neglect. Staff had a good understanding of what safeguarding was and what to do to raise their concerns. Staff were trained in safeguarding to have up to date knowledge. In relation to safeguarding, one visiting professional told us, “We do not currently have any concerns about Malsis Hall.”

The provider did not always record how to manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them, but this was not always consistently recorded to a high standard in risk assessments.

People were not always included in decisions on how to manage risks. While we found some risk assessments were high quality, person centred and clear, this was not the case for all people. Some people’s risks were not clearly assessed which impacted on how staff were able to consistently and confidently support the person to manage the risk. Leaders were aware of this inconsistent approach to records and had a plan in place to improve the quality of risk assessments for all people. One person told us, “It is very good here. I feel safe. I get on with everyone.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was clean, tidy and hygienic. The service had all safety checks such as gas safety checks, electrical safety checks, fire risks assessments and ligature risks assessed and minimised. Fire drills were routinely completed and there were established protocols in place to escalate environmental risks. A member of staff responsible for the maintenance of the service told us, “We keep a clear record of all the checks we do. We keep on top of it [maintenance] and we’re proud of the standard of the maintenance.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff to make sure people received safe care. There was a clear staffing protocol for three staff to one person and there was also a review process with commissioners when someone needed one to one support. Leaders at the service worked hard to recruit permanent staff and reduced their reliance on agency staff. This had a positive impact for people as they established positive relationships with staff they were familiar with. One member of staff told us, “There is always enough staff. It has been better recently, now we don’t use agency staff as much.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The risk of infection transmission was safely managed. There were cleaning schedules in place and housekeeping staff successfully kept the living environment clean and hygienic. We observed staff washing their hands and using personal protective equipment (PPE) when supporting someone with care tasks.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines to be given ‘when required’ did not always have person centred information to support staff to know when to give them. When people were prescribed more than one medicine as and when needed for the same condition, there was not always information to support staff to know when to give one medicine in preference to another. There was a risk people might not have received their medicines when they needed them. When people were given a ‘when required’ medicine the effects of the administration of the medicine was not always recorded, therefore the effectiveness of the medicine could not be monitored.

Medicine administration records were not always accurately completed; therefore, it was not always possible to know the reason why medicines were missed. When people had continually refused their medicines for a period of time, staff did not always take action to notify the prescriber, which placed people at risk of harm.

The site of application of topical preparations, such as patches, was not recorded; this meant the manufacturers guidance to rotate patches might not have been adhered to, which placed people at risk of skin irritation. When people were prescribed a cream, there was not always detailed information to support staff to know where to apply the cream. This meant people’s skin might not be cared for properly. In addition, when people were prescribed a paraffin based topical preparation, a fire risk assessment had not been completed in line with national guidance. This is important as some creams are known to be flammable.

When people self-administered, or managed their own medicines, there was not always a risk assessment in place.