The Care Quality Commission
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Archived: Hollycroft Care Home

Overall: Requires improvement read more about inspection ratings

16 Hebers Ghyll Drive, Ilkley, West Yorkshire, LS29 9QH (01943) 607698

Provided and run by:
Acegold Limited

Important: The provider of this service changed. See new profile

All Inspections

7 April 2015

During an inspection looking at part of the service

We carried out an announced comprehensive inspection of this service on 28 October 2014. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection on 7 April 2015 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Hollycroft Care Home on our website at www.cqc.org.uk

At the April 2015 inspection we found the new manager had completed the registration process and was now the registered manager for the service.

People and their relatives spoke positively about the service and staff told us they had confidence in the management. We found significant improvements had been made and the home was now compliant with all the regulations we looked at. However, there were only 12 people living at the home which is registered to provide care to 30 people. For us to be assured that the service was able to consistently able to provide good care we would need to see evidence that these improvements were sustained over time and with a greater occupancy level.

Staffing levels were appropriate and people received care in a timely fashion. There was also a good level of management support available in the home.

Systems were now in place to ensure that staff promptly reported incidents such as safeguarding incidents and falls. We looked at how incidents had been managed and saw examples were appropriate action had been taken to help keep people safe.

Staff we spoke with had a good understanding of the Mental Capacity Act (MCA) and how to ensure the rights of people with limited mental capacity when making decisions was respected. We found the home to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Covert medicines were administered correctly in line with the required legal frameworks.

People’s care needs were appropriately assessed and care was delivered to meet their individual needs. Care documentation was up-to-date and there was evidence that regular changes were made to respond to people’s changing needs.

Systems were in place to regularly assess and monitor the quality of the service. This included checks on staff competency, a range of audits such as medication and mealtime experience and regularly seeking the views and feedback of people who used the service.

28 October 2014

During a routine inspection

Hollycroft Care Home provides accommodation and personal care for up to 30 older people at any one time. On the date of the inspection, 28th October 2014, 15 people were living in the service. 

At the last inspection in March 2014 the home met all the regulations we looked at.

A registered manager was not in place.  A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.  There was a newly appointed home manager in post.  They told us they would apply for the registered manager post immediately.

Some incidents of abuse were not properly reported and investigated.  This meant that appropriate action was not always taken to protect people from harm.  This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Consent was not always sought correctly. Care records showed people’s capacity was not assessed under the Mental Capacity Act 2005 (MCA) which meant there was a risk their rights were not protected. We found one person had their medicines administered covertly, but there was no evidence their mental capacity had been assessed or the decision had been made in the person’s best interest.  The service was not meeting the requirements of the Deprivation of Liberty Safeguards. (DoLS).  Restrictions on people’s liberties had not been considered despite the service restricting people’s access out of the building. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Staffing levels were not always sufficient to keep people safe.  There were times in the morning and at lunchtime when we observed there were insufficient staff to meet people’s needs.   

This was a breach of Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Care plan documentation did not always reflect people’s needs, was inconsistently completed and it was often difficult to find key information.  This was a breach of Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We found staff did not demonstrate a thorough understanding of some subjects such as safeguarding and DoLS which was delivered via the computer based system indicating the training was not fit for purpose.  In some cases, training records were missing which meant there was no evidence staff had received appropriate training.  This was a breach of Regulation 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Some care plans contained detailed information which showed people’s needs had been thoroughly assessed to allow staff to deliver appropriate care.  However this was not consistently applied and we found other care plans were missing key assessments and had not been updated following people’s changing needs. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010

A range of activities were on offer. These included activities personalised to people’s individual needs. People reported activities were good and said they choice in the activities they got involved in.

The premises was safely managed.  Appropriate communal space was available as well as a well maintained garden area. Checks on equipment were undertaken to help keep people safe.

Staff, people and relatives spoke positively about the new manager and said they had made a number of improvements in the short time they had been in post. We saw evidence which confirmed this was the case, for example around improving staff morale and communication between the staff groups.  However further work was required to the services quality assurance system to ensure it proactively identified and rectified care quality issues.  This was a breach of Regulation 10  of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010

4 March 2014

During a routine inspection

We spoke with four people who used the service. They all told us they were happy with the care provided at the home. People's comments included:

'Staff are very helpful to me, when I fell they quickly checked me to find out if I was ok.'

'Happy here, it is a good home.'

'It is very nicely run, they listen to me.'

We spoke with two relatives. One told us they were very happy with the care provided, another relative said they had complained about some elements of their relatives care and were waiting to see if these concerns had been appropriately addressed.

We found that people's needs were assessed so that appropriate care was planned and delivered.

We found the provider had systems in place to monitor the quality of the service it provided. This included undertaking audits and seeking the views of people and their relatives.

The provider had systems in place to ensure the Commission was notified following allegations of abuse, deaths, serious incidents and other notifiable incidents.

Records contained appropriate information on the care and treatment of people who used the service, although we found it was sometimes difficult to find information as it could be located in a number of areas within care records.

16 April 2013

During an inspection in response to concerns

We spoke with eight people who lived at Hollycroft and three visitors. They all told us they were happy with the care and support provided. One person said 'Hollycroft does not feel like a care home, it feels like my home'. Another person said 'staff look after us really well, we get everything we need when we need it'.

The people and visitors we spoke with were happy with the environment of the home. One person told us 'staff keep the place clean and tidy, I have everything I need in my room'. People also told us they received support from staff when they needed it and that they didn't have to wait long for someone to come and help them if they pressed the call bell in their room.

Despite the positive comments people made about the care provided, we found evidence the provider did not have an effective system to regularly assess and monitor the quality of service people received. We also found evidence people were not always protected from the risks of unsafe or inappropriate care as care records were inconsistent and unclear. We also saw that incidents which had affected the health, safety and welfare of people who lived at Hollycroft had not been reported to the Care Quality Commission (CQC).

16 December 2012

During a routine inspection

People who used the service said they were pleased with the care and support provided by the home. They said staff were polite and cheerful. They also said they were kind and caring. A relative said:"Care was good. Now staffing levels had dramatically improved staff had more time for people in the home." They also said people were now "listened to."

We were also told since the new manager had started work at the home, "Things had improved and there was confidence in her."

Another relative said they had no complaints.

We found people were given appropriate information and were involved in making decisions about their care and treatment. People told us staff treated them with respect and courtesy. One person said, "They always ask me my opinion."

People told us they were well cared for. One person said, "The staff were very good and kind." We found that people's needs were assessed and care was planned and delivered in line with their individual care requirements.

Staff received professional development and people told us staff were well trained.

We saw the provider had systems in place to gather feedback from people, who used the service, and to regularly assess and monitor the quality of service people received.