CQC report explained · a nursing home
What the CQC found at Holy Name Community Rehabilitation Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely. Fire evacuation practice and some infection-control-related premises issues also needed attention, although staffing, recruitment and safeguarding arrangements were positive.
- Effective?
- Requires improvement
- Mental capacity assessments, best-interest records and care planning did not always show that people's needs and decisions had been properly assessed. Staff received training and people had access to health professionals.
- Caring?
- Good
- People were treated with dignity and respect. Staff were caring, compassionate and supportive, and people were encouraged to remain as independent as possible.
- Responsive?
- Good
- Staff knew people's preferences and responded to changing needs. However, some care plans were not detailed enough, and end-of-life care plans did not always guide staff fully.
- Well-led?
- Requires improvement
- Managers were approachable and the culture was open and caring. However, audits and systems for identifying risks and improving quality were not reliable enough.
What inspectors found, June 2023
Holy Name Community Rehabilitation Centre was rated Requires Improvement; inspectors found kind, responsive care but concerns about medicines, risk records and oversight.
This was an unannounced inspection on 17 May 2023. Inspectors spoke with people, relatives, staff and health professionals. They reviewed care and medicine records, recruitment files, audits and the building.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also Requires Improvement. Caring and Responsive were rated Good.
Inspectors found medicines were not always managed safely. Some records, risk assessments and care plans were incomplete or unclear. The quality checks did not always identify these problems.
People were treated with dignity and respect. Staff were described as kind and caring, and people said they felt safe and well looked after. The home must send an action plan, and the CQC will monitor progress.
Kind and respectful care
People, relatives and professionals spoke positively about the staff. Inspectors saw calm and meaningful interactions, with people treated respectfully.
“People were well supported and treated with dignity and respect.” from the report
Enough staff
Inspectors found enough staff on duty to respond to people's needs. Recruitment and induction processes supported safety.
“There were enough staff on duty each shift to safely support people.” from the report
Good partnership working
The home worked with GPs, community nurses, therapists and other professionals to support people's health, rehabilitation and discharge home.
“The registered manager worked closely with several community health and social care professionals to ensure people maintained their health and wellbeing.” from the report
Open management
Managers were described as visible and approachable. The registered manager was open to feedback and willing to make improvements.
“We found the registered manager to be open and honest throughout the inspection.” from the report
Medicine records and guidance
seriousInstructions for some medicines were missing or incomplete. Stock records did not always match, and guidance for medicines given when needed was not always available.
“Medicines were not always managed safely.” from the report
Risk and care records
seriousRisks were not always clearly recorded, and measures to reduce harm were not always available to staff. Some care plans and records lacked important detail.
“Risks associated with people's care had not always been clearly recorded in their care plan or risk assessments” from the report
Quality checks did not find problems
seriousAudits were in place but did not reliably identify concerns with medicines, care records and risk management.
“Systems designed to monitor the safety and quality of the service and take action to mitigate risk, were not robust.” from the report
Mental capacity records
needs fixingRecords did not always show that mental capacity assessments and best-interest decisions had been completed properly, including when restrictions were used.
“There was a lack of information in records to show mental capacity assessments and best interest meetings had been completed in accordance with the MCA.” from the report
End-of-life planning
needs fixingEnd-of-life care plans did not always give staff enough guidance about the support people needed.
“End of life care plans did not always guide staff on support required to ensure people's needs were met.” from the report
Fire evacuation practice
needs fixingThe home could not show that staff had completed time-simulated evacuations. The provider said this would be addressed immediately.
“There was no evidence to support staff completing time simulated evacuations.” from the report
- 01What has been changed so medicine administration records, stock levels and guidance for medicines given when needed are now checked and completed?
- 02How are risks, including risks linked to people's diagnoses, recorded and made clear to all staff?
- 03How do you check that care plans reflect people's assessed needs and give staff enough detail?
- 04How are mental capacity assessments and best-interest decisions recorded when restrictions or medication decisions are involved?
- 05Have staff completed the required time-simulated fire evacuations, and what evidence can you show?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control; it was the first inspection under the new provider. This explanation was written from the published report of 6 June 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.
Every inspection of Holy Name Community Rehabilitation Centre
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Holy Name Community Rehabilitation Centre →
- August 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- August 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2021
Registered with the Care Quality Commission on 15 November 2021.
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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