Archived: Holly Grange Residential Home

Updated 22 February 2024

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

The inspection was completed by two inspectors and an Expert 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

Holly Grange Residential Home 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. Holly Grange Residential Home is a care home without 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 not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the 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 spoke with 9 people who use the service and 6 relatives about their experience of the care provided. We spoke with 9 members of staff, including the provider, manager, and care workers. We observed staff interactions with people whilst delivering care and support in communal areas during mealtimes, medicines administration and provision of activities.

We reviewed a range of records. This included 6 people’s care records, multiple medicine records and daily notes. We looked at 3 files in relation to the recruitment and supervision of staff. We examined a variety of records relating to the management of the service, including policies and procedures, quality assurance audits, and health and safety records.

Updated 22 February 2024

About the service

Holly Grange Residential Home is a care home providing accommodation and personal care for up to 19 people aged 65 and over, some of whom may be living with dementia. At the time of inspection, the service was supporting 9 people in one extended and adapted building on the ground and first floor of three storeys.

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

Risks were not always safely managed. Known risk were not always assessed and mitigated and information on people’s risks to support staff in understanding what they needed to do had not always been recorded.

Medicines were not always safely managed, we found concerns with the recording, storage and stock checks of medicines. ‘As required’ medicines did not have protocols in place to ensure staff had the information required to administer medicines as prescribed.

People were put at risk of harm. We found concerns with unsafe mobility equipment, support with eating, hot food temperatures not being recorded and people having access to harmful substances. A staff member told us at times physical interventions were used for 1 person. Staff did not have the training or systems in place to protect people from the possible risks associated with inappropriate physical interventions.

Staffing levels were not sufficient to meet people’s individual needs. We observed communal areas with people who required support being left unattended throughout the inspection.

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. Consent had been given by people without the legal authorisation to do so

Systems and processes were either not in place or not effective in ensuring good management oversight of the service. When audits had been completed, they did not always identify the concerns found on inspection. Incidents, accidents, wounds and falls had not been analysed to identify any trends and patterns to reduce the risk of reoccurrence.

Care planning documentation was not always detailed with information regarding people’s individual needs. Not all care plans were person centred. However, some people had detailed ‘This is me’ documents which included their history, likes/dislikes and important relationships.

People were supported by staff who had been safely recruited, trained, inducted into the service and who felt supported by the manager. People told us staff were kind and caring. Staff understood safeguarding procedures and how to recognise signs of abuse.

People were protected from risks associated with their health conditions. Staff had the information required and supported people to access healthcare as required.

The provider had policies including complaints, safeguarding, recruitment, infection control and health and safety. The provider had requested feedback on the service offered from people, relatives and staff.

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 Inadequate (published 23 December 2022) and there were breaches of regulation.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

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

Enforcement and Recommendation

We have identified breaches in relation to risk management, medicines, staffing, consent and management oversight at this inspection.

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.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service remains 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.