Archived: Holly Court Care Home

Updated 31 August 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

The inspection was undertaken by 1 inspector and 1 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

Holly Court Care 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. Holly Court 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 a registered manager in post. They were absent at the time of this inspection, and we spoke with the deputy manager.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 18 June 2023 and ended on 10 July 2023. We visited the location’s service on 20 and 23 June 2023.

What we did before the inspection

We reviewed information we had received about the service since the last 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 sought feedback from the local authority and other professionals involved with the service. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people about the care they received, and 3 relatives about their experience of the service provided. We spoke to 8 members of staff including the deputy manager, 3 care staff, 1 team leader, the activity co-ordinator, maintenance staff and the cook.

We reviewed 3 staff files in relation to recruitment. We looked at 4 people’s care plans and risk assessments. We reviewed records relating to medicines management and a variety of records relating the management and quality monitoring of the service. We spoke with a visiting health professional and a social worker undertaking a review of care.

Updated 31 August 2023

About the service

Holly Court Care Home is a residential care home providing accommodation and personal care to up to 25 older people and those living with dementia. At the time of our inspection there were 25 people using the service.

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

Medicines were managed safely and risks to people and the environment had been assessed. People told us they felt safe and considered there were enough staff to offer support; staff felt there were times when another member of staff was needed. A dependency tool was not in use, and we have made a recommendation about this. A dependency tool helps providers determine staffing levels are appropriate based on the number of people living at the home and their individual care needs.

Recruitment practices were robust, and people and relatives spoke positively about staff approach. There were systems and processes in place to safeguard people from the risk of abuse. The home was clean and free from odours.

Staff received a mixture of on-line and face-to-face training covering mandatory elements. Staff new to care completed the Care Certificate. People’s rights were respected, and the service was working in accordance with the Mental Capacity Act.

People had mixed views about the food and drinks offered to them. The provider and registered manager needed to make improvements to the environment and to staff practice to ensure mealtimes were a more positive experience for people.

People were supported to maintain relationships which were important to them and were involved in a range of activities. People’s communication needs were met and there was a process for managing complaints and concerns.

Quality monitoring and audits at the service were not effective or robust. These systems had not identified the shortfalls we found in the dining experience, care planning and electronic systems. These needed to accurately reflect the care provided.

People and relatives spoke positively about the management team and staff commented on the positive teamwork approach in the home.

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 29 November 2022) and there were breaches of regulation in relation to the administration of medicines, staff training and good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made, however the provider remained in breach of regulations.

Why we inspected

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

We carried out an unannounced comprehensive inspection of this service on 12 and 13 October 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to the Key Questions of safe, effective, responsive and well-led.

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 has remained requires improvement based on the findings at this inspection.

At this inspection we found the provider had made improvements in relation to the administration of medicines, staff training and the provision of activities, but they remained in breach of good governance. We have made a recommendation in relation to staffing.

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

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.