25 July 2022
During an inspection looking at part of the service
Malvern House is a residential care home providing accommodation for persons who require nursing or personal care to up to eight people. The service provides support to older and younger adults, who may have a physical disability, learning disabilities or autistic spectrum disorder or require support with their mental health. At the start of our inspection there were three people living at the home.
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
People’s experience of using this service and what we found
Right Support: The provider failed to have safe and robust systems to meet people’s individual needs when their behaviours were of such an intensity, frequency or duration that their physical safety was likely to be placed in serious jeopardy.
People were not 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 policies and systems in the service did not support this practice.
Right Care: The provider failed to consistently help people have a good quality of life that supported their physical and mental health and emotional wellbeing while promoting their dignity and human rights.
Right Culture: The provider failed to act in a timely manner to ensure everyone living at Malvern House lived in a safe clean environment that promoted their privacy. The provider failed to ensure that staff interventions when people were in crisis were safe, proportionate and measurable through accredited training and comprehensive documentation.
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 24 May 2021) 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 the provider remained in breach of regulations.
At our last inspection we recommended that audit systems be reviewed so the concerns we found could be identified by the provider. We also recommended the provider personalise policies and procedures to reflect the management structure of Malvern House. At this inspection we have found the same concerns and they were in breach of regulation 17.
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.
The inspection was prompted in part due to concerns received about the management of risk related to the support people received while living at Malvern House. A decision was made for us to inspect and examine those risks. As a result, we carried out a focused inspection to review the key questions of safe, effective and well-led only.
We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this report.
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 requires improvement to inadequate based on the findings of this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Malvern House on our website at www.cqc.org.uk.
Enforcement and Recommendations
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 and will take further action if needed.
We have identified breaches in relation to people not being consistently protected from the risk of abuse. Systems did not always lessen risks for people and they were not consistently treated with dignity and respect and staff did not always act in accordance with the requirements of the Mental Health Act 2005. Staff had not received all the required training to support people safely and effectively at this inspection and governance systems failed to identify the concerns found at this inspection. We have imposed conditions on the providers registration as a result of this inspection.
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.
Special measures
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.