CQC report explained · a nursing home
What the CQC found at Glenholme Holdingham Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People received their medicines safely and staff understood safeguarding and risk management. Some people reported slower call bell responses at night, and kitchen cleaning and food labelling needed better monitoring.
- Effective?
- Good
- Care was based on people's needs, choices and preferences. Staff training and supervision were up to date, and the environment had been improved for people living with dementia and sensory loss.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff supported people's choices, mobility, personal care and pain relief.
- Responsive?
- Good
- Care plans were personalised and reviewed regularly. People could take part in a wide range of activities, maintain relationships and access the community.
- Well-led?
- Good
- Quality checks, record keeping and management systems had improved. The home had a positive and open culture, but night-time call bell monitoring still needed further development.
What inspectors found, January 2024
Rated Good; inspectors found kind, well-organised care, with some delays to night-time call bells and kitchen monitoring needing attention.
This was an unannounced follow-up inspection. Inspectors visited on 7, 13 and 14 December 2023. They spoke with people living at the home, relatives, staff and health professionals, and checked care records, medicines, staffing and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that medicines were managed safely, care plans were personalised and regularly reviewed, and people were treated with dignity and respect.
There were some concerns. Some people said call bells could take longer to answer at night. Inspectors also found that cleaning schedules and food labelling in the commercial kitchen needed better monitoring. These issues were raised during the inspection and action was taken or planned.
Safe medicines management
Medicines were administered as prescribed. Staff had relevant training and their competence was checked regularly.
“People received their medicines safely, as they were prescribed.” from the report
Kind and respectful care
Inspectors saw staff treating people respectfully and supporting their privacy, dignity and independence.
“People were well supported and their privacy and dignity respected and promoted.” from the report
Personalised care
Care plans included people's life histories, preferences, communication needs and required support. They were reviewed monthly or sooner.
“Care plans and risk assessments were well written, person-centred and reviewed regularly.” from the report
Activities and social contact
People could join activities in their rooms, in groups and in the community. Relatives were able to visit freely and were included in social events.
“People were able to access a broad range of meaningful activities whether at the service or in the community.” from the report
Improved management
The home had made improvements since the previous inspection, including better quality checks and records. It was no longer in breach of regulations.
“At this inspection, the provider had made sufficient improvements, and the service was no longer in breach of the regulation.” from the report
Night-time call bells
needs fixingSome people said call bells were not always answered quickly at night, particularly when there was an emergency. The existing system could not provide data to analyse response times, although management planned checks and a system update.
“The system used did not allow for the data to be analysed.” from the report
Kitchen monitoring
minorInspectors were not always assured that hygiene practices in the commercial kitchen were being monitored well enough. Cleaning schedules and some food and date labelling needed better oversight, although these were corrected when raised.
“Cleaning schedules, some food and date labelling in the fridges required better monitoring.” from the report
- 01How quickly are night-time call bells answered now, and how do you check this?
- 02Has the call bell system been replaced or updated so response times can be analysed over time?
- 03What daily checks are now made on kitchen cleaning schedules and food date labelling?
- 04How are medicines staff assessed to make sure they remain competent to manage medicines safely?
- 05How will you involve relatives when reviewing improvements following this inspection?
This was an unannounced follow-up inspection covering all five CQC questions and checking improvements required after the previous inspection. This explanation was written from the published report of 30 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2021
Rated Requires Improvement; inspectors found risks around staffing, medicines, staff attitudes and quality checks.
This was an unannounced focused inspection on 16 March 2021. Inspectors looked at whether the home was safe, caring and well-led. They spoke with people, staff, managers and a relative, and checked care, medicine, staffing and management records.
The home was clean and risks to people's care had been assessed. However, staffing levels did not always meet people's needs. Inspectors also found missing guidance for some medicines, unclear allergy records and staff not always following mask and laundry guidance.
The rating stayed at Requires Improvement, as it had at the previous inspection. Improvements meant the home was no longer in breach of the dignity and respect regulation, but it remained in breach of Regulation 17 because its quality checks had not found or fixed important problems.
Care risks assessed
Inspectors found that risks linked to people's care needs and the environment had been assessed, with plans showing staff how to reduce those risks.
“People were protected from risks associated with their care needs.” from the report
Clean home
The home was clean and maintained, with checks on cleaning arrangements.
“The home was clean and well maintained. Regular checks had been carried out to ensure cleaning regimes were effective.” from the report
Safe recruitment and training
Staff had training for their roles, and recruitment checks included references and Disclosure and Barring Service checks.
“There were safe recruitment processes in place to ensure people were supported by suitable staff.” from the report
Dignity and choice
Inspectors observed staff respecting privacy and supporting people to express their views and make decisions about care.
“We found people's dignity was respected.” from the report
Staffing levels
seriousThere were not always enough staff to support people. Inspectors heard that people could wait for help at night, and observed people left without staff support in communal areas.
“There were not always adequate numbers of staff to ensure people were well supported.” from the report
Medicine records
seriousSome as-required medicine protocols were missing, and allergies were not always recorded on medicine administration sheets. Inspectors said this created a risk that people might not receive medicines when needed or might receive a medicine they were allergic to.
“There was a risk people would not receive their medicines when needed.” from the report
Infection control practice
needs fixingStaff did not always wear masks as required. Dirty laundry was also carried unbagged through communal areas, creating a risk of cross infection.
“There was a risk of cross infection.” from the report
Person-centred care
needs fixingCare was not consistent. Inspectors observed a delay in providing requested pain relief, and heard concerns about patronising language and people having to buy preferred foods.
“Care was not consistently person centred.” from the report
Quality checks
seriousThe home's audits did not consistently identify problems found during inspection. The provider remained in breach because its systems had not produced sustained improvement.
“This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
- 01What has changed to make sure there are enough staff at night, including when two staff are needed to support one person?
- 02How are you checking that every as-required medicine has an up-to-date protocol and that allergies are recorded on the medicine administration record?
- 03What action has been taken about concerns regarding staff attitudes and how people are spoken to?
- 04How do your current quality checks make sure problems with medicines, PPE and care records are found and corrected?
- 05What was the outcome of the action plan and any follow-up inspection after this report?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected, and the inspection included infection prevention and control. This explanation was written from the published report of 30 April 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Glenholme Holdingham Grange
3 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- January 2024Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2021Requires improvementstayed Requires improvementSafe: Requires improvementCaring: Requires improvementWell-led: Requires improvement
- July 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2018
Registered with the Care Quality Commission on 11 July 2018.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
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