We carried out a review of the data available to us about Holly Oak Care Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Holly Oak Care Centre, you can give feedback on this service.
Holly Oak Care Centre is a residential nursing home providing personal and nursing care to up to 46 people. The service provides support to people living with a diagnosis of dementia or age-related frailty. At the time of our inspection there were 25 people using the service.
People’s experience of using this service and what we found
People and their relatives told us the service was safe and staff responded to their needs safely. There were enough staff deployed to meet people’s needs. Staff told us they had the skills, time and support they needed to meet people’s needs.
Staff had received training in recognising safeguarding and knew the actions to take to protect people from harm. Improvements had been made to recruitment processes which the provider and registered manager used to assure themselves of the good character of staff.
The provider had infection control procedures in place to protect people and prevent the spread of infection. Staff accessed personal protective equipment (PPE) and acted in accordance with government guidance.
People's needs, and choices were assessed, and their care was reviewed regularly. Care records identified people's individual risk and how these should be managed to reduce the risk of harm.
We observed positive interactions throughout our inspection between people and staff. Incidents and accidents were reviewed to reduce the risk of a reoccurrence. Complaints were responded to appropriately and opportunity was made to identify and make improvements.
People and their relatives spoke positively about the management and the caring culture of staff. The registered manager was supported by the provider.
Mental Capacity Act
Staff supported people in the least restrictive way possible and in their best interests. Where people were living under Deprivation of Liberty Safeguards; staff understood the support they required.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 25 May 2022)
Why we inspected
This was a focused inspection based on the rating of the service. We followed up on action taken following our April 2022 inspection and the improvements the provider told us they were going to make.
We undertook this focused inspection to check if they now met legal requirements. This report only covers our findings in relation to the safe and well led.
This was a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
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 Oak Care Centre 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.
Holly Oak Care Centre is a residential care home providing personal and nursing care to 21 older people living with dementia at the time of this inspection. The service can support up to 45 people.
People’s experience of using this service and what we found
Staff and people spoke positively about the registered manager and the support they received. While some monitoring systems were in place to manage the services, the service records did not always show where action had been taken following audits to address the identified shortfalls. We made a recommendation to the provider regarding their good governance systems.
Safe recruitment practices had not always been followed and pre-employment checks had not always been undertaken to gather assurances about staff’s previous employment and conduct.
People received care which was safe, and staff understood how to support people to maintain their safety. People’s needs were clearly assessed, and their care plans promoted person centred care. Staff used technology and recognised techniques to carry out care which promoted the independence and wellbeing of people living with dementia.
People's medicines were managed and administered well. The registered manager and staff worked with people’s representatives and healthcare professionals to ensure people’s needs were reviewed and care carried out in their best interest.
At the time of our inspection the home was managing a COVID-19 outbreak. Care staff used personal protective equipment (PPE) and supported people to reduce the risk of infection. This included supporting people to isolate.
Staff received support to carry out their roles through training and regular meetings with senior staff.
People received engagement and support from a staff team that followed a whole home approach to meaningful engagement. This included one to one activities and group activities such as quizzes, singing and dancing. People were comfortable with staff and enjoyed support which was tailored to their wellbeing needs.
People were supported to have as much choice and control of their lives as possible, 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
This service was registered with us on 13 January 2021 and this is the first inspection.
Why we inspected
This inspection was a planned inspection based on the service being newly registered. This service had not been inspected since their registration; therefore, this inspection was carried out to gain assurances about the quality of care and systems used to monitor and manage the service.
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.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We made a recommendation to support the provider’s oversight of the quality monitoring systems.
We have identified a breach in relation to safe recruitment practices at this inspection.
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.