Archived: Holmside Residential Care Home

Updated 13 August 2016

The inspection took place on 11 and 12 May 2016 and was unannounced. This meant that the provider and staff did not know we would be visiting. The inspection was carried out by one inspector. We also sought advice from the CQC pharmacy team.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 to look at the overall quality of the service and to provide a rating for the service under the Care Act 2014.

We spoke with 12 people and three relatives. We also conferred with a reviewing officer from the local NHS trust; a challenging behaviour practitioner from the local mental health trust, a local authority safeguarding officer, a local authority contracts officer and a local authority fire safety officer.

We spoke with the registered manager; deputy manager; senior care worker, three care workers, activities coordinator, domestic and the cook. We also telephoned two night staff on the first day of our inspection so we could ascertain how care was delivered at night. We read three people’s care records and two staff files to check details of their recruitment and training. We looked at a variety of records which related to the management of the service such as audits, minutes of meetings and surveys.

Prior to carrying out the inspection, we reviewed all the information we held about the home. The manager completed a provider information return (PIR) prior to our inspection. A PIR is a form which asks the provider to give some key information about their service, how it is addressing the five questions and what improvements they plan to make.

Updated 13 August 2016

The inspection took place on 11 May 2016 and was unannounced. This meant that the provider and staff did not know that we would be visiting. We carried out a second announced visit to the home on 12 May 2016 to complete the inspection.

We last carried out an inspection on 6 June 2014, where we found the provider was meeting all the regulations we inspected.

Holmside Residential Care Home provides care to a maximum of 39 older people, including those with a dementia related condition. There were 30 people living at the home on the first day of our inspection and 29 on the second day.

There was a registered manager in post. A registered manager is a person who has registered with the CQC 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.

A quality assurance system was in place. We found however, that this was not always effective in identifying the concerns which we had highlighted. We highlighted some shortfalls with health and safety and the management of controlled drugs. We also found deficits regarding the maintenance of records relating to recruitment, the MCA and assessments relating to people’s care and support.

A new extension had been built in 2015 comprising of 12 bedrooms and a reception area with tea and coffee making facilities. The premises were well maintained, we saw however, that some of the first floor windows had not been fitted with window restrictors to reduce the risk of any accidents or incidents. In addition, a comprehensive Legionella risk assessment had not been undertaken although water checks and tests had been carried out to monitor for Legionella bacteria.

We received mixed comments about whether there were sufficient staff on duty. There were two staff on night duty to look after 30 people. An assessment had not been carried out to ascertain whether night staffing levels were adequate to evacuate people safely in an emergency. We passed our concerns to the local authority’s fire safety team.

Following our inspection, we wrote to the provider using our legal powers to request information about how they were going to ensure people's safety. The provider informed us that window restrictors had now been fitted to all windows and there were now three staff on duty at night. We will follow this up at out next inspection.

We found shortfalls in the management of controlled drugs (CD’s). Not all CD’s had been entered into the CD register in line with legal requirements.

We checked recruitment procedures at the service. Staff told us that the checks were carried out before they started work at the service. We found that documented risk assessments had not been completed if any concerns were found during these checks.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. We spoke with a local authority contracts safeguarding officer who told us that there were no organisational safeguarding concerns regarding the service.

The manager provided us with information which showed that staff had completed training in safe working practices and to meet the specific needs of people who lived there such as dementia care training.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’ it also ensures unlawful restrictions are not placed on people in care homes and hospitals.” The manager had submitted DoLS applications to the local authority to authorise in line with legal requirements. She was strengthening the service’s paperwork to ensure that it evidenced how the requirements of the MCA were met.

We observed that staff supported people with their dietary requirements. Staff who worked at the home were knowledgeable about people’s needs. We observed positive interactions between people and staff. There was a part time activities coordinator employed to help meet the social needs of people.

There was a complaints procedure in place. Feedback systems were in place to obtain people’s views. Meetings and surveys were carried out.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safe care and treatment, staffing and good governance. You can see what action we told the provider to take at the back of the full version of the report.