Hollybank Nursing Home

Updated 28 November 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.

Inspection team

The inspection team consisted of 2 inspectors and an and 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

Hollybank Nursing 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. Hollybank Nursing Home is a care home with 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.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

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 reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, Healthwatch and professionals who work with the service. 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 all this information to plan our inspection.

During the inspection

Inspection activity started on 24 October 2023 and ended on 27 October 2023. We visited the service location on 24 October 2023. We spoke with three people who used the service and 6 people’s relatives. We spoke with 7 members of staff, including the registered manager, deputy matron, 4 care assistants and a housekeeper.

We completed observations of care in communal areas. 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 including 5 people's care records, food and fluid charts and other monitoring records. We also reviewed a range of medication administration records, 2 staff recruitment files and records relating to the management of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at staff training records and a variety of audits.

Updated 28 November 2023

About the service

Hollybank Nursing Home is a 'care home’. It provides nursing and personal care in one adapted building for up to 30 older people, including some who live with dementia. It accommodates people over 2 floors and it has got a specious garden. At the time of our inspection there were 25 people using the service.

People’s experience of the service and what we found

People were not always fully protected from the risk of harm because the provider's approach to risk management was not consistent. There was an increased risk that people could be harmed because potential hazards and risks were not always identified and there were no clear strategies to reduce them, this included the risk of infection control. Information about risks and safety was not always clearly documented.

People’s human and legal rights were not fully understood, because consent to care and treatment had not been obtained in line with legislation and guidance, including the Mental Capacity Act 2005 and Deprivation of Liberty safeguards. People’s assessments of needs were not always comprehensive and some people’s care plans lacked important details about how to deliver care and support.

Governance and quality assurance at the service were not always effective. The provider’s systems and processes such as regular audits of the home were not sufficiently robust in monitoring and improving the quality and safety of the service. Saff did not have access to up to date policies and procedures. This impacted their knowledge of current best practice guidance and put people at increased risk of harm.

People felt protected from abuse, neglect and discrimination.

People were supported by adequately trained, sufficient number of staff. People, their relatives and staff all confirmed this. People were supported with their medicines safely by the nursing staff. When people required additional support from external services, they were promptly referred by staff who were skilled in recognising when people’s needs change.

People enjoyed their meal time experience and they had access to food and drinks of their choice at all times. People’s diet was tailored to their individual needs and preferences.

People and their relatives found the home to be a homely and happy environment. Whilst the home was in need of cosmetic uplift, the communal areas and people’s bedrooms were suitable for people’s needs. There was also a large garden available for people.

People, their relative and staff spoke highly of the management team. They felt the home had an open culture, where the manager was available to support them and encouraged feedback, both positive and negative.

The provider worked effectively with other agencies. This included taking prompt actions in response to feedback.

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 Good [published 30 June 2018].

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We undertook a focused inspection to review the key questions of safe and well-led only. During the inspection we found there was a concern with ensuring consent to care and treatment in line with law and guidance, so we widened the scope of the inspection to include the key question of effective. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

Enforcement

We have identified breaches in relation to safe care and treatment, deprivation of liberty and good governance. Add paragraph space below

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

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 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.