Holly Bank Care Home

Updated 12 November 2022

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

This inspection was conducted by 1 inspector 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. The Expert by Experience spoke with people who use the service and their relatives by telephone.

Holly Bank Care 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 Bank Care 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 a registered manager in post. The registered manager is also the provider for this service. We refer to them as ‘the provider’ throughout this report.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Before the inspection, we reviewed all the information we held about the service including information about important events which the service is required to tell us about by law. We requested feedback from other stakeholders. These included the local authority safeguarding team, commissioning teams and Healthwatch Calderdale. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. 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 of this information to plan our inspection.

During the inspection

We spoke with 9 people using the service and 6 of their relatives about their experience of the care provided. We observed care in the communal areas to help us understand the experience of people.

We gathered information from 5 members of staff including the provider, deputy manager and care staff.

We reviewed a range of records. This included 4 people's care plans, risk assessments and associated information, and other records of care to follow up on specific issues. We also reviewed multiple medication records. We looked at 3 staff files in relation to recruitment, training, supervision and appraisals. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 12 November 2022

About the service

Holly Bank Care Home is a residential care home for to up to 25 people who require support with personal care needs, some of whom are living with dementia. The service does not provide nursing care. There were 24 people living at the home at the time of our inspection. Bedrooms are situated over four floors and there are three lounges and a dining room on the ground floor.

Since the last inspection the registered manager has also become the provider of the service. We refer to them as ‘the provider’ throughout this report.

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

There were safe systems of recruitment in place. Staffing levels had been increased to make sure people’s needs could be met safely at all times. Medicines were managed safely. Staff received safeguarding training and knew what to do if they thought someone was at risk. Risks to people and the environment were identified and well managed. People’s needs were assessed, and clear risk assessments were in place to guide staff.

Everybody we spoke with said they, or their relative, felt safe. One person who lived at the home when asked if they felt safe said, “Absolutely, spot on no bother.” A relative said, “Yes, indeed. I know the staff well and know them by name. I know that they work to the highest standards and I trust them. I am very grateful for the care (relative) receives there.”

People’s relatives gave examples of how accidents and incidents were managed well and how they were kept informed, where appropriate, of what was happening with their family member.

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. Risks associated with COVID-19 were well managed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People said the service was well led. The provider had ensured the service continued to improve since the last inspection. We found systems to assess, monitor and improve the service were established and effective. The provider and deputy manager had good oversight of the service and demonstrated passion and commitment to the continued development of 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 (published 6 September 2019). 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 18 July 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 Good. This is based on the findings at this inspection.

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

Follow up

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