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.
What inspectors found, November 2022
Holly Bank Care Home is rated Good; inspectors found safe care and stronger management after earlier problems.
This was an unannounced, focused inspection on 20 October 2022. The inspector and an Expert by Experience spoke with people, relatives and staff, observed care, and checked care records, medicines, recruitment files and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, well-managed risks, safe medicines procedures and suitable infection control measures. People and relatives said they felt safe.
Management systems had improved. Audits and checks were being used to find and address problems, and people and staff said they could raise concerns. The overall rating changed from Requires Improvement to Good.
This visit only checked Safe and Well-led. The other key question ratings were carried forward from the previous inspection, so this report does not give fresh findings about those areas.
Safer staffing
Staffing levels had been increased, including an extra member of staff available at night for emergencies. Inspectors found enough staff to meet people's needs safely.
“A night sleep in duty had been introduced to make sure there was always an extra member of staff available at night” from the report
Risk management
People's health and safety risks were assessed clearly. Staff had information about the actions needed to reduce the chance of harm.
“People's needs were assessed, and clear risk assessments were in place to guide staff.” from the report
Safe recruitment and safeguarding
The home followed safe recruitment procedures. Staff had safeguarding training and knew how to report concerns.
“There were safe systems of recruitment in place. Staffing levels had been increased to make sure people's needs could be met safely at all times.” from the report
Effective management checks
The provider had improved audits and monitoring. Records showed that issues found through these checks were dealt with.
“Audits and spot checks were thorough, and records showed any issues identified were addressed.” from the report
People's views were heard
The home asked people for their views and acted on survey results. People said they could raise concerns with management.
“People confirmed their opinions about the service were sought. We saw results of quality surveys were collated and analysed.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you check that staffing levels remain enough for the needs of everyone living here?
- 02What extra support is available at night if a resident has an emergency?
- 03How are my relative's individual risks recorded and explained to staff?
- 04How will you support someone living with dementia, including any extra help needed with medicines?
- 05What were the findings of the previous inspection in the Effective, Caring and Responsive areas, and when will these areas next be reviewed?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 12 November 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.
What inspectors found, September 2019
Rated Requires Improvement; inspectors found kind, personalised care but too few night staff and weak provider oversight.
This was an unannounced inspection on 18 July 2019. Inspectors spoke with five people living at the home, three relatives, nine staff members and a visiting healthcare professional. They also checked care records, medicines records, staff files and management records.
The home was rated Good for Effective, Caring and Responsive. Inspectors found kind staff, personalised care, safe medicines management, good support with healthcare and improved activities.
The home was rated Requires Improvement for Safe and Well-led. There were still too few staff at night, which meant people sometimes waited for help and created a risk during an evacuation. The provider had also not acted properly on known problems or on the previous staffing breach.
The overall rating remained Requires Improvement, the same as at the previous inspection in April 2018. The provider was in breach of regulations about staffing and good governance.
Kind and respectful staff
People and relatives gave good feedback about staff. Inspectors saw staff treating people with dignity and respect.
“Interactions between staff and people about their personal care needs was discreet.” from the report
Personalised care
Care plans reflected people's choices, routines and dignity needs. People and families were involved in developing and reviewing them.
“Care plans were person-centred and contained direct quotes from the person.” from the report
Safe medicines practice
Inspectors found good systems for medicines, including clear guidance for medicines prescribed to be used when needed and checks on staff practice.
“Our checks of stocks and records showed there were good practices in place to ensure medicines were managed safely.” from the report
Improved activities
People said activities and opportunities to socialise had improved since the new manager was appointed. People enjoyed social events.
“All of the people we spoke with told us there had been real improvements in relation to provision of activities and encouraging people to socialise.” from the report
Too few staff at night
seriousNight staffing was not enough to meet people's needs safely. People said they often waited for assistance, and inspectors identified a risk to safe evacuation.
“People we spoke with gave examples of how too few staff meant they often had to wait for assistance at night time.” from the report
Provider did not act on known problems
seriousThe provider had not fixed issues identified through audits or acted on the previous staffing breach. Provider visits did not always happen.
“However, the overall governance processes lacked rigour because the provider's oversight was inconsistent and did not provide clear direction and empowerment.” from the report
People's menu suggestions were not always used
minorPeople were asked for menu ideas, but the menu did not include all the choices they had made.
“However, we saw the menu in place did not include all of the choices people had made.” from the report
CCTV consent was unclear
needs fixingCCTV operated in communal areas, but inspectors did not see evidence that people had been asked about it or had given consent to 24-hour surveillance.
“We did not see evidence people had been asked about this or given consent to 24 hour surveillance.” from the report
- 01How many staff are now on duty at night, and how is this number matched to residents' needs?
- 02What action has been taken to make sure the home can be evacuated safely at night?
- 03How often do provider oversight visits now take place, and how are actions from audits tracked to completion?
- 04How are residents' menu suggestions recorded and included in future menus?
- 05How are residents and their representatives asked for consent or views about CCTV in communal areas?
This was a planned, unannounced inspection covering all five key questions, with the whole home and the care provided examined. This explanation was written from the published report of 6 September 2019 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 6 years: the service has improved, from Inadequate to Good.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2016InadequateSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- September 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 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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At least 100 live-in carers within about an hour of Calderdale
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.
Most charge £980 to £1,260 a week. 87 can care for a couple. 12 years' experience on average.
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