CQC report explained · a residential care home
What the CQC found at Holt Mill House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some health and environmental risks were not properly assessed or dealt with. Medicines, staffing, recruitment, infection control and safeguarding arrangements were otherwise found to be satisfactory.
- Effective?
- Requires improvement
- Staff were knowledgeable and people received support with food, healthcare and communication. However, training in areas including safeguarding, fire safety and equality and diversity was not up to date, and some consent records needed to be clearer.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Their equality, cultural needs, privacy, independence and choices were supported.
- Responsive?
- Good
- Care plans were personalised and people were supported to communicate, maintain relationships and take part in activities. Some care plan areas and end of life paperwork needed improvement.
- Well-led?
- Requires improvement
- The home had a positive and open culture, but audits had not identified several risks and there was little evidence of regular provider audits. Systems for learning from issues also needed to be stronger.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found kind, person-centred care, but risks, staff training and management checks were not reliable enough.
The inspection took place over 8 and 9 November 2023. One inspector visited during normal hours and out of hours, spoke with people, a relative and staff, and checked care, medicine, recruitment and management records.
People were treated kindly and respectfully. They were supported to make choices, keep relationships and take part in activities. Medicines were administered safely, the home was clean, and staffing levels and recruitment were suitable.
However, some important risks were not properly assessed or dealt with. These included missing risk assessments for diabetes and asthma, hot water, uncovered radiators and delayed emergency lighting work. Staff training was also not up to date.
The overall rating changed from Good in 2018 to Requires Improvement. The same rating applies to Safe, Effective and Well-led. Caring and Responsive remained Good. The provider was required to send an action plan and will be monitored.
Kind and respectful care
People were treated well and their privacy, dignity, independence and equality needs were respected.
“People were treated well and their equality and diversity needs were respected.” from the report
Activities and relationships
People were supported to keep in touch with loved ones and take part in activities that matched their interests.
“People were supported to maintain relationships, follow their interests and take part in activities that were relevant to them.” from the report
Medicines managed safely
Inspectors found that medicines were administered safely and that records and stock counts were accurate.
“Records and pill counts were accurate and the daily handover covered medicines information in a good level of detail.” from the report
Positive culture
People, relatives and staff gave positive feedback about the management. Staff described an open and supportive culture.
“There was a positive and open culture at the service.” from the report
Risks were not consistently managed
seriousA person did not have risk assessments for diabetes or asthma. Hot water, uncovered radiators and missing emergency lighting also created safety risks.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Staff training was out of date
seriousStaff had not completed all required updates, including safeguarding, fire safety and equality and diversity training.
“Although staff were knowledgeable, we found staff were not up to date with a number of training courses including safeguarding, fire safety and equality and diversity” from the report
Management checks missed problems
seriousAudits did not identify environmental risks, missing care paperwork or training shortfalls. Provider oversight was not formal or robust enough.
“We found no evidence people had been harmed. However, systems were either not in place or robust enough to demonstrate records and governance was effectively managed.” from the report
Some records needed improvement
needs fixingConsent records, parts of care plans and end of life paperwork were not sufficiently clear or complete. No one was receiving end of life care during the inspection.
“Care plans carried little information in relation to people end of life care plans and staff had not received training in this area.” from the report
- 01Have the missing diabetes and asthma risk assessments now been completed and reviewed?
- 02Have the hot water temperatures, radiator covers and emergency lighting been corrected?
- 03Which staff training was overdue, and can you show that safeguarding, fire safety and equality and diversity training is now up to date?
- 04What new checks are being used to make sure care records, environmental risks and staff training are identified promptly?
- 05How have consent records, care plans and end of life paperwork been improved since the inspection?
This was an announced inspection covering both floors, normal and out-of-hours care, people’s experiences, care and medicine records, recruitment records and the management systems across all five rated questions. This explanation was written from the published report of 16 December 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, January 2018
Holt Mill House was rated Good; inspectors found kind, personalised care, with some training and medicines-record issues to address.
This was an announced inspection on 13 December 2017, with short notice because the home is small and people were often out during the day. Inspectors reviewed care records, medicines, staff records, rotas, training, complaints, maintenance and quality checks. They also spoke with staff, a relative, one person and two healthcare professionals, and observed care.
The home supported three adults with a learning disability or autistic spectrum disorder. Inspectors found people were treated with kindness and respect. They found good arrangements for safeguarding, risks, staffing, medicines, cleanliness, food, healthcare and activities.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. It was also rated Good at the previous inspection in March 2015, so the report says the service remained Good. Inspectors did identify some out-of-date first aid training, unclear instructions for some external medicines, unmonitored medicine-storage temperatures and gaps in the training records.
Kind and respectful care
Inspectors saw people treated with kindness, care and respect. Staff knew people well and used familiar ways to communicate with them.
“During this inspection we observed people were treated with kindness, care and respect.” from the report
Personalised support
Each person had a detailed support plan based on their wishes, preferences, goals and communication needs. People were supported to be as independent as possible.
“Each person had a support plan which provided clear guidance on how their needs and preferences would be met.” from the report
Meaningful activities
People were supported to take part in activities suited to their interests and abilities, including activities outside the home and holidays.
“People were supported to live full and active lives and use local services and facilities.” from the report
Stable staffing
The staff team was stable, and inspectors found enough staff to provide flexible and personalised support. Staff said they felt valued and supported.
“There were sufficient numbers of staff to ensure people's care and support was provided flexibly.” from the report
First aid training
seriousSome first aid training was out of date. The manager said updated basic life support training had been booked for all staff.
“However, we noted some of the first aid training was out of date.” from the report
Medicine instructions and storage
seriousInstructions for applying external medicines were not always clear, and storage-area temperatures had not been monitored. The manager said this would be addressed and further training was planned.
“However, we noted the directions for application of external medicines were not always clear and the temperatures of medicine storage areas had not been monitored.” from the report
Training records
needs fixingThe training matrix had gaps, suggesting some staff had not received recent update training. The manager said the matrix would be updated.
“However, we noted there were a number of gaps in the training matrix which indicated staff had not received recent update training.” from the report
- 01Has all first aid and basic life support training been brought up to date since the inspection?
- 02How are instructions for applying external medicines checked for clarity?
- 03How are medicine-storage temperatures recorded and reviewed now?
- 04How do you make sure staff update training is completed and accurately recorded?
- 05How will my relative and family be involved in reviewing the personalised support plan and activities?
This was an announced inspection covering the premises, care provided and all five CQC questions; the report says the ratings remained Good from the previous inspection in March 2015. This explanation was written from the published report of 11 January 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 Holt Mill House
3 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Registered with the Care Quality Commission on 21 January 2014.
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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