22 November 2023
During a routine inspection
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.