Archived: Hollycroft Nursing Home

Updated 2 February 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked 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.

The inspection of Hollycroft Nursing Home took place on 21 and 24 November 2014 and was unannounced. The inspection was undertaken by one inspector.

Before the inspection we looked at and reviewed the Provider’s Information Return (PIR). This questionnaire asks the provider to give some key information about its service, how it is meeting the five key questions, and what improvements they plan to make. We also looked at notifications of incidents that the provider had sent us. Notifications are reports that the provider is required to send to us to inform us about incidents that have happened at the service, such as accidents or a serious injury.

During our inspection we spoke with 10 people who used the service, four relatives, one member of kitchen staff, one nurse, three care staff, the registered manager and the regional manager. We observed care and support provided in communal areas and spoke to people in their bedrooms.

We reviewed a range of records about people’s care and how the service was managed. These included pathway tracking five people by reviewing their care records, looking at the staff training matrix, four staff recruitment records, three people’s medication records and the quality assurance audits that the registered manager completed. We looked at some policies and procedures which related to safety aspects of the service and also looked at the whistle blowing and safeguarding policies. Prior to our inspection we contacted several healthcare professionals who had regular contact with the service, including commissioners to obtain their views about the care provided by the service; we spoke to or received feedback about the service from four of the professionals we contacted.

Updated 2 February 2015

This unannounced inspection took place on 21and 24 November 2014. At our last inspection in September 2013 the service were meeting the regulations of the Health and Social Care Act 2008.

Hollycroft Nursing Home is registered to provide accommodation, nursing or personal care for up to 37 people. At the time of our inspection 32 people were using the service. People using the service may have a range of needs which include dementia, physical disability or old age. Whilst some people lived there permanently the service also provides care to people on a short term rehabilitation basis, often following discharge from hospital.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (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 2008 and associated Regulations about how the service is run.

Staff were knowledgeable about how to protect people from harm. The manager was able to demonstrate learning and changes to practice from incidents and accidents that had occurred within the service.

We looked at staff rotas and observed there were a suitable amount of staff on duty with the skills, experience and training in order to meet people’s needs. People and their relatives told us they felt confident that the service provided to them was safe and protected them from harm.

People’s nutritional needs were monitored regularly and reassessed when changes in people’s needs arose. We observed that staff supported people in line with their care plan and risk assessments in order to maintain adequate nutrition and hydration.

The staff worked closely with a range of health and social care professionals to ensure people’s health needs were met, for example physiotherapists and occupational therapists.

People’s ability to make important decisions was considered in line with the requirements of the Mental Capacity Act 2005. However, documentation in relation to people’s resuscitation status was not always completed accurately and lacked clear involvement of the individual or those closest to them in making such important decisions.

Staff were responsive when people needed assistance and interacted with them in a positive manner, using encouraging language whilst maintaining their privacy and dignity. People were encouraged to remain as independent as possible.

People were not routinely provided with written information about the day to day routines within the service or about how to make a complaint. Although people lacked information about the service, they told us they were able to ask staff or other people using the service any questions they had. Information regarding how to access local advocacy services was displayed in communal areas.

Activities within the home were limited as the manager was in the process of recruiting a dedicated activities coordinator. During our visit we saw that people were in good spirits and laughed and chatted happily together.

Visiting times were restricted in the evening for those people using the service on a short stay basis; the manager said they would review this following our visit.

People, relatives and visiting professionals spoke positively about the approachable nature and leadership skills of the registered manager. Structures for supervision allowing staff to understand their roles and responsibilities were in place. Staff we spoke with were unclear about the how they could access or how they would utilise the providers whistle blowing policy.

Quality assurance systems had failed to identify issues with recruitment processes and medicines management that may put people using the service at risk. Feedback was sought from people, their relatives and stakeholders as part of the provider’s quality assurance system, but results were not analysed or shared to improve people’s experience of the service.

Recruitment practices within the service were not robust. We saw in some records that appropriate last employer references were not in place and that gaps in staff employment history had not clearly been discussed and reasons for these documented. The manager had failed to document discussions and undertake a risk assessment for staff who were working within the service with a disclosed criminal record. You can see what action we told the provider to take at the back of the full version of the report.