CQC report explained · a nursing home
What the CQC found at Hollybank Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found good staffing levels, safeguarding arrangements and awareness of people's risks. However, recruitment checks were incomplete, some medicines records needed improvement, and checks on gas safety and profiling beds were still being addressed.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- Care plans were personalised and staff understood people's needs and preferences. Some activities were still being reintroduced after COVID-19 restrictions, and one relative had not been involved in developing a care plan.
- Well-led?
- Requires improvement
- Managers carried out audits, but these did not identify all the shortfalls found by inspectors. Where some problems were identified, there was not enough evidence that action had been taken.
What inspectors found, June 2022
Rated Requires Improvement; inspectors found caring staff and good personalised support, but weaknesses in recruitment and quality checks.
This was a focused inspection after concerns about staffing, medicines and risk management. Inspectors reviewed safe, responsive and well-led care. They visited the home, spoke with people, staff, relatives and health professionals, and checked care, medicines, recruitment and safety records.
The home had good staffing levels, kind staff and personalised care. People said they felt safe and well looked after. Care plans, complaints systems, safeguarding arrangements and end-of-life support were generally good. The home was clean and well maintained.
There were important weaknesses. Recruitment checks were not always completed before staff started work. Audits had not found some problems, and managers had not always acted when records showed shortfalls. Medicines records, gas safety checks and some equipment checks also needed improvement.
The overall rating changed from Good to Requires Improvement. The report says the provider breached Regulation 17 on good governance and Regulation 19 on fit and proper staff recruitment. The CQC requested an action plan and said it would continue to monitor the home.
Caring staff
People and relatives spoke highly of the staff. Inspectors saw respectful and caring interactions, and staff understood people's individual needs.
“People and their relatives had high praise for the staff and commented on how some staff went, "above and beyond.” from the report
Good staffing levels
Inspectors found high levels of staff supporting people, and staff described good teamwork.
“From our observations and on review of staff rotas we found high levels of staff provided to support people.” from the report
Personalised care
Care plans recorded people's wishes and preferences. Staff supported people to make choices and responded to requests for help.
“Care plans were personalised and included people's wishes and preferences.” from the report
Safeguarding and risk awareness
Staff knew the signs of abuse and what to do if they had concerns. Staff also understood people's individual risks and how to support them.
“Staff were clearly aware of people's individual needs and areas of potential risk.” from the report
Recruitment checks
seriousSome staff files did not contain all the required information before employment started. Inspectors found unexplained employment gaps, unsuitable or incomplete references and incomplete interview records.
“We found robust systems were not in place when recruiting new staff.” from the report
Weak quality monitoring
seriousAudits did not identify all the problems found during the inspection. When some shortfalls were identified, records did not show that action had been taken.
“However, these were not sufficiently robust and had not identified the shortfalls found during this inspection.” from the report
Medicines records
needs fixingOral medicines were managed safely, but records for creams, when-required medicines and fridge temperatures needed improvement. The manager said these issues were addressed immediately after the inspection.
“Improvements were needed with regards to the completion of topical cream records, reviews of when required medication and fridge temperatures.” from the report
Safety checks still being addressed
needs fixingOutstanding checks relating to gas safety and profiling beds were being addressed during the inspection.
“The operations manager confirmed outstanding action regarding gas safety and profiling beds were being addressed.” from the report
Activities and family involvement
minorSome people felt more activities could be offered. One relative had not been involved in developing a new resident's care plan, and family meetings were being reinstated after lockdowns.
“Two people we spoke with felt other opportunities could be made available.” from the report
- 01What changes have you made to ensure all references, employment gaps, interviews and other recruitment checks are completed before staff start?
- 02How do your current audits identify problems with care records, nutrition, falls and repositioning, and how do you confirm that action is completed?
- 03Have the gas safety and profiling bed checks been completed, and can you show us the latest records?
- 04How are topical cream records, when-required medicines and fridge temperatures now checked?
- 05How will you involve families in care planning and provide activities that match each person's interests?
This was a focused inspection of Safe, Responsive 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 24 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.
What inspectors found, October 2019
Hollybank Care Home was rated Good; inspectors found kind, safe care, with some training, recording and care-plan improvements still needed.
This was a planned inspection over three visits. The first visit was unannounced. One inspector spoke with four people, four relatives and staff, observed care, and reviewed care records, recruitment files, training information and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People and relatives spoke positively about the care. Inspectors saw kind staff, good support for choice and independence, a clean home, improved monitoring of food and drinks, and more activities in the local community.
There were some areas still being improved. Staff turnover had been high, some refresher training was overdue, care plans could be more personal, and a local authority review found some recording shortfalls. The home had action or new systems in place to address these issues.
Kind and respectful care
People and relatives spoke positively about the service. Inspectors saw staff treating people with kindness, dignity and respect, while promoting choice and independence.
“People and relatives spoke positively about their experiences and the quality of care and support offered.” from the report
Food and hydration
The home had significantly improved its monitoring of nutrition and hydration. People enjoyed the homemade food, and staff responded carefully to the risks of dehydration and choking.
“The monitoring of nutrition and hydration had significantly improved, and people enjoyed the homemade food offered.” from the report
Visible management
The management team was described as visible and supportive. Inspectors found regular audits and a whole-team approach involving care, catering, housekeeping and activities.
“Regular audits were undertaken to ensure the service maintained good standards.” from the report
Previous high staff turnover
needs fixingStaff turnover had been high, although inspectors found enough staff to meet people's needs at the time of the inspection. Ask whether the team has remained stable.
“There had been a high turnover of staff. However, we saw the home now had enough staff to meet people's needs.” from the report
Overdue refresher training
needs fixingMost training had been completed, but some refresher training was overdue. The home had written to the staff concerned asking them to complete it.
“The training record showed that most training had been completed but there were was some overdue refresher training highlighted.” from the report
Care plans not fully personal
needs fixingThe managers recognised that care plans could contain more personal detail and were working to improve them.
“The registered manager had already recognised that care plans could be more person centred.” from the report
Recording shortfalls
needs fixingA local authority quality review found some shortfalls in recording. The report says an action plan was already underway.
“The local authority had recently undertaken a Quality Assurance exercise which they found some shortfalls in recording.” from the report
- 01How stable has the staff team been since the inspection, and how do you cover sickness and vacancies?
- 02Have all overdue refresher training courses now been completed?
- 03What changes have been made to make care plans more person centred?
- 04What action was taken after the local authority found shortfalls in recording?
- 05How has the electronic medicines system performed since it was introduced, and what checks are now made for errors or missed medicines?
This was a planned inspection covering all five CQC questions; nursing care was not being provided at the time, although the service was registered to provide it. This explanation was written from the published report of 18 October 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 Hollybank Care Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2019Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- January 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Goodup from Requires improvementSafe: GoodWell-led: Good
- December 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 2010.
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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