Archived: Holmdale House

Updated 8 July 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 24 February 2015 and was unannounced. The inspection team consisted of an inspector and a specialist advisor in the care of frail older people and in particular those living with dementia.

The team inspected the service against four of the five questions we ask about services: is the service safe, effective, responsive and well led. This is because the service was not meeting legal requirements.

Before the inspection, we considered all the information we had received from the provider and information from the local authority safeguarding team who were undertaking an investigation at the home. We used this information when planning and undertaking the inspection. We reviewed information we already held about the service including notifications. A notification is information about important events which the service is required to send us by law.

We spoke with four people using the service, one family member and a social care professional. We also spoke with the registered provider, the registered manager and four care staff. We looked at records including care plans and associated records for six people; staff training and supervision records; one staff recruitment file; records of accidents and incidents; policies and procedures; and quality assurance records. We observed care and support being delivered in communal areas including the lounge and the dining room over the lunch time period.

Updated 8 July 2015

We undertook this focused inspection on 24 February 2015 and it was unannounced. This was to check that the provider and registered manager had followed the requirements of the warning notices issued to them on 5 January 2015 and to confirm that they now met legal requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Holmdale House on our website at www.cqc.org.uk

Following an inspection on 12 & 16 December 2014 we issued three warning notices telling the provider and registered manager they must improve the service provision in these areas by 26 January 2015. The warning notices related to medicines management, safeguarding people who used the service and the failure to ensure that people had their care and welfare needs met. We found the provider had not taken adequate action to meet the warning notices and become compliant with the regulations.

Holmdale House provides accommodation for up to 31 people who require support with their personal care. The home mainly provides support for older people and people living with dementia. There were 10 people living at the home at the time of our inspection.

The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

Medicines were not managed correctly. Where people were unable to say if they had pain there was no system or procedures to identify pain or ensure pain relief medicine was administered. Therefore people did not receive pain relief medicine when they require it. Medication audits had not identified the failure to administer topical creams as prescribed or the incorrect use of topical creams. Essential safety precautions were not followed in respect of the storage of oxygen. People were at risk due to these failings.

People were not protected from the risk of abuse and neglect. Staff did not recognise some aspects of their care practises as being abusive. People were at risk of developing injuries which may have been preventable and action was not taken promptly to ensure people received correct safe care.

Healthcare advice was not always sought or followed when required. Care records did not always show when medical advice had been sought or what the advice or guidance from medical practitioners had been. Care and support was not planned or delivered in a way that met people’s individual needs or responded to their changing needs.

People’s legal rights were not ensured. The principles of the Mental Capacity Act 2005 were not being followed and Deprivation of Liberty Safeguards (DoLS) not implemented effectively. People’s wishes in respect of how they should be cared for were either not known or ignored.

Staff did not receive the training they required to give them the necessary skills to meet people’s needs safely.

We found the provider had failed to take adequate action and are planning further enforcement action. You can find further information about this at the end of the report.