Archived: Holywell Bay Care Home

On the day of our inspection we observed care staff show kindness and compassion through their actions at times throughout the day.

The staff we spoke with told us a number of changes had been made since our last inspection in July 2013. These included different routines for staff and people who lived at Holywell Bay Care Home.

Respect and dignity regarding people's choices and care needs were not always respected.

Care plans had not been completed to include up to date information on people's specific care needs and choices.

The quality assurance monitoring was not effective. Action plans sent to the Care Quality Commission had not been achieved to ensure people's care was provided to a good standard in a clean and comfortable environment.

Staffing of registered nurses and care workers was inconsistent and one member of staff told us this had an impact on the care that was provided.

Documentation was not held securely or confidentially within the home. Care plans had been completed and printed off with the wrong names on.

During our inspection we walked around the home, spoke with the manager, staff and two people who were visiting their relative. Due to people's dementia needs or mental health needs we were unable to ask them for their views on the service, therefore we carried out a 'Short Observational Framework for Inspection' (SOFI) in the dining room during lunch time to observe the care and treatment that was provided. We also observed the care that people received throughout the two days of our inspection.

The privacy and dignity for people living at Holywell Bay Care home had not been respected at all times. People's personal information was available for others to see.

We found that people who needed full support to mobilise were moved from their beds early in the morning and then back again late in the afternoon, at times against people's expressed choice. This did not respect people's dignity or choice.

We saw that people were not provided with adequate care to meet their needs throughout the day. We observed that people who required assistance and/or encouragement with meals did not receive adequate food and drinks. Charts used to monitor how much a person had consumed were inaccurate and did not identify when people had not eaten.

People who lived at the home were not protected from the risks of abuse as the staff had not received adequate training, were not knowledgeable, and the care plans did not fully direct staff.

The provider had completed some maintenance work that we highlighted as a potential risk to both the people who lived at the home and staff during our inspection in May 2013. However the provider had not taken sufficient action to ensure the building internally and externally was safe.

There were insufficient qualified and unqualified staff on duty to meet the needs of the people living at Holywell Bay care Home.

The home did not have processes in place to monitor the service to ensure the environment and the care provided was safe for people who lived in the home.

People who lived at the home were not protected from the risks of abuse as the incidents and accidents that staff had recorded had not been analysed. Incidents had not been reported to the local authority responsible for investigating any allegations of abuse.

Unplanned restraint had been used when a person had been physically aggressive. The care plans and restraint policy lacked detail to direct staff as to when and how this should be carried out.

Manual handling practices were unsafe and care plans did not direct staff fully on how to assist people with their mobility.

The home was seen to be poorly maintained and unclean. There was no system in place to audit the environment. Risk assessments to reduce the potential risk of injury to staff and people who lived at the home had not been completed.

There was insufficient qualified and unqualified staff on duty to meet the needs of the people living at Holywell Bay Care Home.

The home did not have processes in place to monitor the service to ensure the environment and the care provided was safe for people living at the home.

Care records directed nurses and care workers in how to deliver the care and support each person needed. They contained detailed daily statements about people's ongoing welfare and up to date risk assessments.

We were told that staffing levels had been increased and were being further increased in the two weeks following the inspection in order to meet the diverse needs and dependency of people who used the service.

We were told that there were robust staff support systems in place and access to training relevant to each person's role. We saw there were systems in place to give staff information about how to recognise and report potential abuse.

The environment the home offers, continues to be improved with new fixtures, fittings in the communal areas and carpets. These were just some of the improvements made over the last six months.

Routine and planned maintenance is ongoing in order to ensure the ongoing safety of the home. Audits are ongoing, and include feedback from people who used the service, to ensure the quality of the service is monitored and improved.