CQC report explained · a nursing home
What the CQC found at Holbeach and East Elloe Hospital Trust
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks were not always clearly assessed or managed, emergency evacuation plans lacked detail, and staffing shortages sometimes delayed care.
- Effective?
- Good
- People’s health and nutrition were well supported, staff had appropriate training, and care was planned using recognised tools.
- Caring?
- Good
- Staff were kind and respectful, treated people with dignity, and supported their independence.
- Responsive?
- Good
- Care was personalised and met people’s needs, with support for communication and social activities.
- Well-led?
- Requires improvement
- Leadership was inconsistent, quality monitoring was weak, and people and relatives had limited opportunities to give feedback.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found some safety and leadership concerns but good care and effective support.
Inspectors visited the home unannounced in March 2023 to check the quality and safety of care for 43 older people. They spoke with staff, residents, relatives, and reviewed records.
They found the home was clean and staff were caring and kind. People’s health and nutrition were well managed, and medicines were handled safely. Staff worked well with health professionals.
However, risks to people’s safety were not always well managed. Some care plans lacked clear details, and emergency evacuation plans needed updating. Staffing levels were sometimes low, causing delays in care.
The home’s leadership was inconsistent. Quality checks and learning from incidents were not always effective. People and relatives had few chances to give feedback. The provider is working to improve these areas.
Good health and nutrition support
People’s dietary needs were well managed with specialist advice when needed.
“People's nutritional needs were well managed. People told us the food was varied and of good quality.” from the report
Clean and infection controlled environment
The home was clean and staff followed good infection prevention practices.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Risk management gaps
seriousSome care plans lacked clear instructions to keep people safe, such as how often to reposition those at risk of skin damage.
“For two people whose plans we viewed there was no information about how often these people needed to be repositioned or encouraged to reposition.” from the report
Emergency evacuation plans incomplete
needs fixingPersonal emergency evacuation profiles did not have clear individualised information before being updated after inspection.
“The personal emergency evacuation profiles (PEEPs) we viewed, lacked clear individualised information on the support people would need to evacuate the service in an emergency.” from the report
Staffing shortages
seriousStaffing levels were sometimes too low, causing people to wait up to 40 minutes for personal care.
“People and relatives told us people could be waiting for personal care for up to between 30 and 40 minutes.” from the report
Weak quality monitoring
needs fixingAudits and checks were not always done or effective, limiting learning from incidents and oversight of care.
“Quality monitoring audits had not been undertaken for some months and the medicines and care plan audits the deputy manager had completed were not available for us to view on the day of our inspection.” from the report
- 01How has the home improved staffing levels to reduce waiting times for personal care?
- 02What changes have been made to ensure risks to safety are clearly assessed and managed?
- 03How does the home involve people and their families in giving feedback about the care?
- 04What steps are in place to improve leadership and quality monitoring at the home?
- 05How are emergency evacuation plans personalised and kept up to date?
This was a comprehensive inspection covering all key areas of care and management. This explanation was written from the published report of 16 May 2023 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, November 2021
Rated Requires Improvement; safety and leadership improved to Good, but the overall rating carried forward earlier ratings for areas not inspected.
This was an unannounced focused inspection on 29 September 2021. Inspectors checked whether earlier problems with safe care and the management of the home had been put right. They spoke with people, staff, health professionals and 12 relatives or friends, and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found that risks were assessed, medicines were generally managed safely, infection controls were in place and there were enough staff on the inspection day. They also found better quality checks, open communication and care that reflected people's choices.
There was one isolated medicines administration problem, which was raised with the manager and addressed promptly. Some people and relatives felt staffing could be tight at times. The overall rating remains Requires Improvement because ratings for the other key questions were carried forward from the previous comprehensive inspection and were not checked during this visit. The two previous breaches had been resolved.
Risks were managed
People's safety risks were assessed and staff followed care plans, including plans for repositioning and the safe use of specialist equipment.
“The risks to people's safety were well managed, and measures were in place to reduce risks where possible.” from the report
Medicines were mostly safe
Medicines records contained clear information, storage was safe and regular audits were used to identify problems. The one issue found was dealt with promptly.
“Despite the above concern all other aspects of medicines administration were safe.” from the report
Improved management checks
The home had a more comprehensive system for checking care and the environment. Actions identified through these checks were completed in a timely way.
“There was a comprehensive quality monitoring system in place at the service.” from the report
Person-centred support
Staff asked people about their preferences and supported them to make choices about their daily routines and where they spent their time.
“Relatives gave us examples of how they knew their family member's care was person centred and empowering.” from the report
One medicines error
needs fixingInspectors saw one isolated example of poor medicines administration. They raised it with the manager, who took prompt action and introduced measures to reduce the chance of it happening again.
“We did observe one isolated instance of poor administration practice which we raised with the registered manager.” from the report
Staffing could feel tight
minorPeople and relatives gave mixed feedback and said the home was busy, with staffing sometimes feeling tight. Staff said cover was arranged when people were off sick or on holiday, and inspectors found staffing was safe on the day.
“People and relatives felt the service was busy and at times staffing was "tight".” from the report
- 01What exactly happened in the isolated medicines administration incident, and what checks are now in place to prevent a repeat?
- 02How do you cover shifts when staff are off sick or on holiday, and how do you respond when staffing feels tight?
- 03What are the current ratings for Effective, Caring and Responsive, which were not assessed during this inspection?
- 04How will quality monitoring and oversight be maintained after the deputy manager left the home?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 13 November 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 Holbeach and East Elloe Hospital Trust
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Holbeach and East Elloe Hospital Trust →
- November 2021Requires improvementstayed Requires improvementSafe: GoodWell-led: Good
Read what inspectors found at Holbeach and East Elloe Hospital Trust →
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 2011.
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.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.