CQC report explained · a residential care home
What the CQC found at Holly Park Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2022
Rated Requires Improvement; the home is no longer in Special Measures after improvement, but inspectors still found gaps in medicines, care planning and oversight.
Inspectors visited without notice on 17 and 24 May 2022. They spoke with people living in the home, relatives and staff, and reviewed care, medicines, recruitment and management records.
The home had improved since its previous Inadequate rating. Inspectors found people generally felt safe, there were enough staff, infection controls were in place, and staff had suitable training. The home was no longer breaching the regulations identified at the previous inspection.
However, some medicines records and checks were still incomplete. Care plans did not always give staff enough information, families were not always involved in care planning, and people's end of life wishes had not been recorded. Quality checks also needed further development.
The overall rating is Requires Improvement. The home had been in Special Measures since August 2021, but inspectors decided it was no longer Inadequate or in Special Measures. The home is still being monitored.
People felt safe
People and relatives spoken with said they felt safe. Staff understood how to respond to abuse concerns.
“All of the people we spoke with said they, or their relatives felt safe.” from the report
Staff training
Staff had completed relevant induction and training, and received regular supervision.
“Records showed staff followed, and were up to date with, a comprehensive programme of training.” from the report
Person-centred information
The home's 'This is me' documents recorded people's likes, dislikes and what mattered to them.
“The documents were very person centred and detailed, demonstrating people's likes, dislikes and what is important to them.” from the report
Complaints handling
Complaints were investigated and followed up with actions, including regular meetings with a concerned family.
“Complaints were thoroughly investigated and responded to with follow up actions taken.” from the report
Medicines checks
needs fixingSome medicines records, fridge temperature checks and instructions for medicines given when needed were not fully complete. Inspectors asked for these issues to be included in monthly audits.
“However, further improvement was needed to make sure they always accurately reflected the prescription and included detail about the effects of overuse of medicines that can cause drowsiness.” from the report
Care plan detail
needs fixingSome care plans did not explain clearly enough what staff should look for or do when people's health or behaviour changed.
“Care plans did not always contain sufficient detail to make sure staff knew what to do to make sure people's needs were met.” from the report
End of life wishes
needs fixingThe home had forms for recording end of life wishes, but none of the records inspectors saw had been completed.
“Documentation for planning people's end of life wishes and care was in place, but none of the one's we saw had been completed.” from the report
Family involvement
needs fixingRecords did not always show that people or their families had been involved in assessments and care planning.
“Records lacked evidence of people or, where appropriate, family being involved in the assessment process.” from the report
Quality oversight
needs fixingAuditing systems were in place but needed further development, particularly for medicines management. There had also been changes in management and some people did not know who the current manager was.
“Systems for auditing safety and quality were in place but needed some further development particularly in relation to reviewing medicines management.” from the report
Outdoor space
minorRelatives said the existing outdoor area was not comfortable enough, although the provider had plans to improve it.
“Two people's relatives raised concerns about the lack of comfortable outdoor space.” from the report
- 01How are you checking that medicines records, fridge temperatures and instructions for medicines given when needed are now complete and accurate?
- 02How will you involve my relative and our family in developing and reviewing the care plan?
- 03When will my relative's end of life wishes be discussed and recorded?
- 04What information has been added to care plans so staff know how to respond to changes in health or agitation?
- 05Who is currently managing the home, and what is the progress of their application to become registered manager?
This was a focused inspection of Safe, Effective, Responsive and Well-led only; Caring was not inspected and the report does not give a new rating for it. This explanation was written from the published report of 1 July 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, August 2021
Holly Park Care Home was rated Inadequate and placed in special measures after inspectors found risks with medicines, premises, infection control and management.
This was an unannounced focused inspection. Inspectors visited on 12 and 18 May 2021, with inspection activity continuing until 8 June 2021. They spoke with people, relatives and staff, and checked care records, medicines, recruitment files and management records.
The home was not consistently safe. Medicines were not always given as prescribed, risks were not properly assessed, some unsafe areas were accessible, and infection control was not robust. Records did not always explain people's needs or preferences, and clinical staff did not have enough supervision and support.
The overall rating fell from Requires Improvement to Inadequate. The home had not made enough progress since the previous inspection and had been rated Inadequate or Requires Improvement at the last five consecutive inspections. It was placed in special measures.
Staffing levels
People and staff said there were enough staff to meet people's needs. The home used a dependency tool to work out staffing levels.
“People told us there were enough staff.” from the report
Recruitment
The inspection found safe recruitment processes intended to check that staff were suitable to work with vulnerable people.
“Safe recruitment processes were in place to ensure staff were suitable to work with vulnerable people.” from the report
Safeguarding
Staff knew how to recognise and report abuse. Safeguarding incidents were recorded and investigated.
“Staff were aware of the signs of abuse and how to report any concerns.” from the report
Approachable management
People and relatives said the manager and staff were approachable. Relatives also said they were kept informed about management changes and their family member.
“People told us the manager and staff were approachable.” from the report
Medicines
seriousSome medicines were not given as prescribed, including a pain-relieving patch that was applied a day late. Records and checks were not always reliable.
“Some medicines had not been given as they were out of stock, including a pain-relieving patch that was applied a day later than it should have been.” from the report
Risks and unsafe areas
seriousSome people's risks were not assessed properly. Unlocked storage areas contained tools, screws and chemicals, and temperature problems were not shown to have been resolved.
“We could freely access the area and hazards such as a saw, screws, pliers, screwdrivers, chemical lubricant aerosol and paint.” from the report
Infection control
seriousInspectors were not assured that infection prevention measures were strong enough. They found problems with screening, protective clothing and cleaning.
“We were not assured that the provider had robust infection and prevention measures in place.” from the report
Care records
seriousCare records were incomplete and did not consistently describe people's needs, choices or preferences. One person did not have their own care record.
“People did not have accurate and complete records detailing their care and support needs.” from the report
Clinical support
seriousClinical staff had not started clinical supervision or reflective practice. Inspectors were not assured that they had the support needed for their roles.
“Although we saw evidence new staff received induction, shadowing and training, clinical supervision and reflective practice had not commenced.” from the report
Working with health professionals
seriousRecords did not show enough partnership working with health professionals. There was a delay in arranging appropriate catheter care.
“There had been a delay in providing appropriate catheter care due to failing to notify the relevant healthcare professional that a person required a replacement catheter.” from the report
- 01How do you now check that every medicine is available, given as prescribed and recorded by the staff member who administered it?
- 02What has been done to secure maintenance areas and resolve the temperature and fire-safety concerns found by inspectors?
- 03How do you make sure every person has a complete, personalised care plan that includes their choices and preferences?
- 04What evidence can you show that clinical staff now receive supervision and reflective practice?
- 05How are you making sure healthcare professionals are contacted promptly about needs such as catheter care, swallowing support and diet?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 20 August 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 Holly Park Care Home
6 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- July 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- March 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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