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Holly Park Care Home Inadequate

Inspection Summary

Overall summary & rating


Updated 20 August 2021

About the service

Holly Park Care Home is registered to provide accommodation, personal and nursing care for up to 43 people who may be living with dementia or other mental health conditions. There were 26 people using the service at the time of inspection.

People’s experience of using this service and what we found

Not enough improvement had been made since the last inspection in May 2019, and the provider continued to be in breach of regulation 9 (person-centred care), regulation 12 (safe care and treatment), regulation 18 (staffing) and regulation 17 (good governance). The service has failed to achieve a good rating and has a history of breaching regulations since being registered with the CQC in January 2011.

Medicines were not always managed safely. Infection control practices were not sufficiently robust to be assured the risk of infection was being mitigated. The provider was not taking appropriate steps to assess risks to people and to keep the premises safe.

People did not have an accurate and complete care record. The care records were not person-centred and did not focus on how the person wanted their care and support needs to be delivered. There was insufficient information to demonstrate the provider was working effectively with other healthcare professionals to ensure care was provided and planned in a timely manner.

The provider’s audit systems were not effective as we found the breaches from the previous inspection had not been addressed.

People and staff told us there were enough staff to meet people’s needs. Safe recruitment processes were in place to ensure staff were suitable to work with vulnerable people. People told us the manager and staff were approachable. Relatives told us they were kept up to date with management changes and about their family member.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 June 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection not enough improvement had been made and the provider was still in breach of regulations. The service had deteriorated to inadequate. This service has been rated either inadequate or requires improvement for the last five consecutive inspections.

Why we inspected

At the last inspection on 29 April 2019 and 1 May 2019, breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve person centred care, safe care and treatment, good governance and staffing.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Holly Park on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19

Inspection areas



Updated 20 August 2021

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 20 August 2021


Requires improvement

Updated 20 August 2021


Requires improvement

Updated 20 August 2021



Updated 20 August 2021

The service was not well-led.

Details are in our well-led findings below.