CQC report explained · a nursing home
What the CQC found at Hollybank Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Rated Requires Improvement; inspectors found some safety and legal concerns, but people felt cared for and staff were supportive.
Inspectors visited Hollybank Nursing Home unannounced in October 2023 to check the quality and safety of care. They spoke with people living there, relatives, and staff, and looked at records and the environment.
They found that the home was not always safe. Risks to people’s health and safety were not always properly assessed or managed. Infection control was not fully effective, and some equipment was not clean. Staff knew how to protect people from abuse, and people said they felt safe.
The home was not always effective in following the law about consent and deprivation of liberty. Some people were restricted without the correct legal authorisation. Care plans sometimes lacked important details, especially for people receiving end of life care.
The management and leadership were not always strong. Systems to check and improve the quality of care were not robust. Policies were out of date, and risks were not always identified. However, the home had a positive culture, staff felt supported, and the management responded quickly to feedback.
Staff training and support
Staff were well trained, received supervision, and felt supported by management.
“All staff completed a comprehensive induction and training, and did not work unsupervised until they and their manager were confident they could do so.” from the report
Good meal experience
People had enough food and drinks of their choice, and mealtimes were relaxed and well supported.
“We observed lunch time which was not rushed and was supported by enough members of staff to provide personal support.” from the report
Risk management
seriousRisks to people’s health and safety were not always identified or managed, including infection control and emergency evacuation plans.
“Risk assessments relating to the health, safety and welfare of people using the service were not always completed or reviewed regularly and did not always include plans for managing risks.” from the report
Legal rights not fully respected
seriousThe home did not always follow the Mental Capacity Act and did not apply for legal authorisation when restricting people’s freedom.
“The provider did not apply for authorisation of a deprivation of liberty (DOLs) for any of the people prior to our inspection.” from the report
Outdated policies and poor governance
needs fixingPolicies were not up to date and quality checks were not robust, leading to missed issues before inspection.
“Several policies and procedures were not detailed, up-to-date or in line with current legislation because they were not reviewed for several years.” from the report
- 01How do you assess and manage risks to keep people safe, including infection control?
- 02What steps have you taken to ensure legal requirements for consent and deprivation of liberty are met?
- 03How do you update and review care plans to make sure they include all important information?
- 04What improvements have you made to your policies and quality checks since this inspection?
- 05How do you support and train staff to provide safe and effective care?
This inspection looked at safe, effective and well-led; other ratings carried over from 2018. This explanation was written from the published report of 28 November 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 2018
Hollybank Nursing Home was rated Good; inspectors found kind, safe care, with some improvements needed to cleanliness, signage and family involvement.
This was an unannounced comprehensive inspection on 18 April 2018. Inspectors spoke with people living in the home, relatives, staff and a visiting health professional. They reviewed care records, staff recruitment files, medicines records and management checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were protected from abuse, medicines were managed safely, and staff were safely recruited. Staff understood people's care needs and supported their health, nutrition, choices and rights.
Inspectors found staff to be kind and respectful. Care was tailored to people's routines and preferences. The home also supported activities, family contact, religious practice and end of life care.
There were some shortfalls. A few areas were not clean enough, and signage and other aids for orientation were not always in place. The home later told inspectors that it had taken action. Group meetings for people and relatives were also not held regularly. The rating improved from Requires Improvement at the September 2016 inspection.
Kind and respectful staff
Inspectors saw staff protecting people's privacy and dignity. People and relatives said staff knew them well and built good relationships.
“People received care from staff who were kind, caring and promoted their dignity and rights.” from the report
Safe medicines and recruitment
Medicines records were accurate and staff handling medicines were trained and checked. Required employment and vetting checks were completed before staff started care work.
“People's medicines were safely managed, stored and given to people when they needed them.” from the report
Personalised care
Staff followed people's preferred routines, food choices and communication needs. People could take part in activities, community life and religious practice as they wished.
“People received timely, individualised care in a way that met with their known daily living preferences and lifestyle choices.” from the report
Improvement since the last inspection
The home had addressed the earlier concerns about unsafe recruitment and inaccurate records for risk-assessed care needs. The overall rating improved from Requires Improvement to Good.
“At this inspection we found the improvements needed had been made.” from the report
Good health and nutrition support
Staff understood people's health conditions and involved outside health professionals when needed. They supported people to eat and drink enough food that met their needs and preferences.
“People were supported by staff to eat and drink sufficient amounts of food they enjoyed.” from the report
Signage and orientation aids
minorDirectional signs and other aids to help people find their way and remain independent were not consistently provided at the inspection. The provider later said it had taken action.
“Some people found and we also saw that directional signage and relevant aids, to support people's environmental orientation and independence were not consistently provided.” from the report
Limited regular meetings
minorMeetings for people and relatives were not held regularly, and survey results were not routinely shared. The manager agreed to review consultation and information-sharing arrangements.
“Group meetings were not regularly held with people or their relatives and any survey results were not routinely shared with them.” from the report
- 01What checks are now used to make sure all areas remain clean and hygienic, and what happens if a problem is found?
- 02What directional signs and other aids are now available to help people with orientation and independence?
- 03How often are meetings held for people and relatives, and how are survey results and decisions shared?
- 04How do you check that care plans accurately record each person's risks and required care?
- 05How do you make sure staffing levels and staff training continue to meet people's nursing and personal care needs?
This was an unannounced comprehensive inspection covering all five CQC questions, including the premises and care provided. This explanation was written from the published report of 30 June 2018 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 Nursing Home
3 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- November 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- December 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 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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62 live-in carers within about an hour of Derbyshire
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 £1,010 to £1,260 a week. 51 can care for a couple. 12 years' experience on average.
“Ernest is an amazing professional carer who delivers care from the heart.”
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