CQC report explained · a residential care home
What the CQC found at Holly Bank Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found suitable arrangements for drinks, monitoring people's fluid intake, checking equipment and managing environmental risks. They also found worn and stained carpets and recommended a stronger refurbishment plan.
- Effective?
- Good
- Not assessed in this targeted inspection.
- Caring?
- Good
- Not assessed in this targeted inspection.
- Responsive?
- Good
- Not assessed in this targeted inspection.
- Well-led?
- Good
- Not assessed in this targeted inspection.
What inspectors found, September 2023
Inspected but not rated; inspectors found no evidence of harm from the concerns checked, but some areas needed refurbishment.
This was an unannounced targeted inspection on 22 August 2023. Inspectors followed up concerns about support during hot weather and whether the environment was suitable. They spoke with five people, one relative and five staff, and checked records and information from the provider.
People were offered drinks, with choices kept within easy reach. Staff recorded people's fluid intake and took action when someone was not drinking enough. Heating, water systems and fire safety equipment had been checked and were working properly.
Inspectors found that some carpets and floors needed replacing. They said this could affect cleanliness and infection prevention. The provider had an improvement programme, but inspectors recommended a more robust plan that should be shared with residents, relatives and commissioners.
This was a targeted inspection, so it did not assess the whole service or change the previous ratings. The last overall rating was Good, published in June 2022. The safe question had previously been Requires Improvement and remains not changed because only part of it was examined.
Drinks and hydration
People had access to different drinks, and staff monitored intake and acted when someone was not drinking enough.
“People were supported to eat and drink appropriately and noted there were a variety of drinks available.” from the report
Hot-weather checks
The inspection found no additional concerns about people's support during hot weather.
“During the inspection we noted people were offered drinks and there was a choice of drinks available and within easy reach.” from the report
Equipment safety
Heating, water systems, fire safety equipment and equipment used to help people move were checked.
“Appropriate checks were made of essential equipment and systems.” from the report
Action on low drinking
When staff were concerned that someone was not drinking enough, they monitored the person and took appropriate action.
“When there was a concern people were not drinking enough, they were monitored with action taken in appropriate cases.” from the report
Worn carpets and floors
needs fixingSome parts of the home needed refurbishment. Inspectors said worn and stained carpets could affect cleanliness and infection prevention.
“Some carpets were worn and stained. This could affect cleanliness in the home and was an infection prevention concern.” from the report
Refurbishment plan
needs fixingInspectors said the provider's improvement programme needed to be more robust and recommended sharing it with residents, relatives and commissioners.
“We recommend the provider implements a robust improvement plan in relation to all areas of the home that require refurbishment.” from the report
- 01Which carpets and floors have been approved for replacement, and when will each job be completed?
- 02How will you share the refurbishment improvement plan and progress with residents and relatives?
- 03How do you monitor people's drinks intake, and what action do you take if someone is not drinking enough?
- 04When was the heating and water equipment last checked, and can you show me the safety records?
- 05What checks are made for people who need help to use stairs or move around the home?
This was an unannounced targeted inspection of specific concerns about hot-weather support and the suitability of the environment; the full five key questions were not assessed and the previous ratings carry over. This explanation was written from the published report of 8 September 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, June 2022
Rated Good; inspectors found kind, person-centred care, but safety needed improvement because of staffing, recruitment and some record-keeping concerns.
This was an unannounced focused inspection on 4 and 5 May 2022. Inspectors looked at Safe and Well-led, following concerns about a water leak, the temporary relocation of residents and how the home was managed. They spoke with people, relatives, staff and healthcare professionals, and reviewed care and management records.
The overall rating was Good. The home was rated Good for Well-led, but Requires Improvement for Safe. Inspectors found that medicines, safeguarding, equipment checks and emergency arrangements were generally managed well. People and relatives mostly described staff as kind and caring, and healthcare professionals praised the support provided.
There were concerns about safe recruitment checks, staffing levels while management cover was unavailable, some care and risk records, and infection control checks for visitors. Some records and infection control arrangements were corrected during the inspection. The provider also increased staffing and introduced improved checks and reviews.
Medicines managed safely
People received their medicines as prescribed. Staff were trained and checks had been made on their medicines practice.
“The interim and deputy managers and staff followed safe processes to ensure people's medicines were managed safely.” from the report
Safeguarding
Staff understood how to recognise and report abuse. People and relatives said they felt safe.
“The provider and interim and deputy managers ensured people were protected from the risk of abuse.” from the report
Working with professionals
The home supported people to access healthcare and worked well with outside professionals, who praised the care and support.
“They [staff] are very responsive to any information I ask whilst attending for the ward rounds.” from the report
Incomplete recruitment checks
needs fixingSome recruitment files did not show checks with previous employers or other required pre-employment considerations. The provider was asked to review its recruitment processes.
“The provider had not always followed safe recruitment procedures.” from the report
Staffing pressure during management absence
seriousA senior carer was covering management duties as well as normal care work. This left the care team short and could mean people did not receive care promptly.
“This left the care team short with the potential people did not receive care and support in a timely way.” from the report
Care records needed updating
needs fixingSome risk records and actions after assessments were incomplete. This could leave staff unclear about people's current abilities and needs, although issues were resolved during the inspection.
“In two files we considered, records and actions following assessment were incomplete and could give staff an unclear position around the status and capabilities of people.” from the report
Visitor infection checks
needs fixingInfection control arrangements at the entrance were not robust enough when professional visitors attended. This was corrected on the second day of the inspection.
“Infection control processes at the entrance to the home were not robust enough and this was only corrected on the second day of the inspection.” from the report
- 01What staffing levels will be in place when the registered manager or other senior managers are unavailable?
- 02How do you make sure all employment history and other pre-employment checks are completed before staff work with residents?
- 03How often are care and risk records reviewed to make sure they reflect people's current needs and mental capacity?
- 04What checks are now carried out for professional visitors entering the home to prevent infection?
- 05What changes were made after the water leak and temporary relocation, and how are emergency arrangements now reviewed?
This was a focused inspection of Safe and Well-led only; the other three key questions were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 16 June 2022 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 Holly Bank Care Home
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- September 2023Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- June 2022GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2021Inspected but not ratedSafe: Inspected but not rated
- July 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- June 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2014
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 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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