Hollyveer House

Updated 26 July 2023

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 carried out by 2 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

Hopes Green 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. Hopes Green 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. A new manager had been in post for 4 days and was in the process of submitting an application to register.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 15 June 2023 and ended on 21 June 2023. We visited the location’s service on 15 June 2023.

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. 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 5 people who used the service and 7 relatives about their experience of the care provided. We spoke with the manager, regional support manager, quality assurance manager, regional manager, 2 kitchen staff, and 3 care staff. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included 3 people’s care records, 8 people’s medication records. We looked at 3 staff files in relation to recruitment and staff supervision. We reviewed records relating to the management of the service including quality assurance monitoring and the services policies and procedures.

Updated 26 July 2023

About the service

Hopes Green is a residential care home providing accommodation and personal care to up to 50 people. The service provides support to older people, some of whom had physical frailty and some who were living with dementia. At the time of our inspection there were 45 people using the service.

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

Medicines were not always managed in a safe way. The providers governance arrangements did not provide assurance the service was well led. We were not assured the systems, processes, and leadership currently in place to oversee the quality assurance of the service were robust and effective and regulatory requirements were not always being met.

People living at the service were happy with the support they received. People felt safe and told us staff were kind and caring and were confident any concerns they may have would be listened to and action taken. Staff understood how to raise concerns and knew what to do to safeguard people.

Risks to people had been assessed, reviewed, and updated in people’s care plans when their needs changed. Staff had access to personal protective equipment (PPE) and there were effective infection prevention control measures in place.

Effective arrangements were in place to ensure recruitment checks on staff were safe. Staff had received an induction and training to enable them to meet people’s needs. Supervisions, appraisals, and competency assessments for staff were carried out and staff told us they felt supported by the senior team.

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.

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 27 October 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when.

At this inspection we found improvements had been made in relation to infection control however we found the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced focused inspection of this service on 26 September 2022. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve in relation to safe care and treatment.

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 remains requires improvement. This is based on the findings at this 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 Hopes Green on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to medicines management, good governance, and the notification of incidents.

Please see the action we have told the provider to take at the end of this report.

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.