Archived: Hollies Nursing and Residential Home Limited

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

Risks were not being managed safely and action was not appropriately taken as a result of accidents and incidents. Not all individual risk assessments had been updated and reflected people’s needs.

Environmental risks and checks on the environment were taking place. We made a recommendation that audits on the environment and identified risks were acted upon in a timely manner.

Gaps in the recruitment of staff were noted. We received mixed feedback about the staffing numbers in the service. Safeguarding concerns were not always being acted on to support investigations in a timely manner. We were somewhat assured about the management of infection prevention and control. We found medicines were not always managed safely in the service.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the systems in the service did not support this practice. Conditions for DoLS authorisations had not always been reflected in people’s records in a timely manner. People’s individual medical needs had not always been monitored and reviews by medical professionals sought. None of the records we reviewed had preadmission assessments in them, we made a recommendation about this. People were positive about the food provided; new menus had been developed. Plenty of supplies of food was seen in the service.

We observed people were in bed for long periods. Records could not confirm positional changes had occurred. People were mostly treated with kindness and dignity and we saw positive caring interactions taking place. People told us they were supported to be independent, we observed people being offered choices and decisions in their care.

Care records were incomplete and daily records did not confirm the appropriate care was provided. There was no evidence of end of life care planning. The nominated individual told us they had developed a full range of new documentation to support the delivery of care to people. There was some evidence of activity planning and activities undertaken but these were from last year. There were very limited activities taking place, we made a recommendation about this.

The registered manager was new to the service and had recently commenced audits. Some of the actions had not been checked to ensure they had been completed. There was some evidence of senior audits being done, which identified some of the failings we have seen at this inspection, but not all. The provider was very open and transparent about the failings and the actions they planned to take to ensure systems protected people from the risk of harm. People were mostly positive about the new registered manager and the senior team, but not all. Meetings were taking place and a range of policies and procedures were noted, these had been updated.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 10 June 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations. The service has now been in breach of regulation for the last three consecutive rated inspections.

At our last inspection we recommended that robust systems were in place to manage safe recruitment of staff. And that the premises and the service was suitable to meet the needs of people living there, as well as a recommendation that people were able to access meaningful and regular activities, of their choosing. At this inspection some improvements were seen however, further improvement was required.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection and to check if improvements had been made.

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.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified breaches in relation to, providing appropriate, dignified and timely care, ensuring systems were in place, completed in, and action taken in relation to risks. The service failed to ensure people were protected from the risk associated with inadequate monitoring of people’s individual needs. They also failed to ensure medicines were managed safely and that systems were robust enough, effective to ensure safeguarding concerns were reported and monitored. We also made a breach in relation to protecting people from the risks of unlawful restrictions, and gaps in MCA and DoLS training. As well as ensuring care records were completed in line with guidance and individual needs, and good governance.

We have issued the provider with a warning notice in relation to regulation 12 (1) (2) (a) (b) (g) Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People who used the service were at risk of harm because the provider failed to ensure systems were in place, completed and action taken in relation to risks. Medicines were not managed safely which put people at risk of harm.

We made recommendations in relation to infection prevention and control, staff knowledge and skills, and safe recruitment of staff. As well as ensuring people’s needs were assessed, that action was taken to address risks in the environment and individualised and meaningful activities were provided.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Hollies Nursing and Residential Home Limited is a residential nursing home, providing accommodation for persons who require nursing or personal care, and treatment of disease, disorder or injury, for up to 37 people, in one adapted building over two floors. 27 people were in the service at the time of the inspection.

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

Since the last inspection a new registered manager and nominated individual had commenced in post. They had identified areas of improvement and development, and actions to be taken.

The provider had addressed some of the issues from the last inspection, however we still found concerns that medicines were not always managed safely. Individual risks were not always being effectively managed and environmental risk assessments would benefit from more detailed information. Accidents and incident records were in place, but these were brief and one person’s record had not been updated following and incident. Environmental checks and servicing were taking place.

There was an ongoing recruitment programme in place. We noted some gaps in the recruitment records. The nominated individual told us a review of the staff records had taken place. We made a recommendation about this. People told us that staffing levels were improving in the service. However, we noted times when staff members were not visible in the communal areas, and they were difficult to locate when people were asking for help and support. Systems were in place to investigate and act on allegations of abuse, this would support lessons learned going forward.

Preadmission assessments had been completed, and we saw professionals had been involved in people’s care. We observed concerns in relation to the support of people during the lunchtime experience. Some areas of the service had been nicely decorated and personalised, however, others were sparse and required upgrading. The nominated individual told us there was a refurbishment plan. There was an ongoing training programme in place, we noted some gaps in the training provided. We were told that the training programme was being reviewed, to ensure all staff had the required training to support them in their roles. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and relatives were positive about the care received. Some people told us they liked their bedroom door wide open however, people’s preferences and choices were not recorded in the care files we looked at. Not all people had access to a call bell system in their rooms. There was no assessment or checks completed that confirmed these people were monitored. The registered manager took immediate action to address this. They reviewed all peoples needs in relation to call bells in the service. Information in relation to advocacy services was available if it was needed.

Care plans were in place however, they had not always been completed in full, updated and signed by staff. Daily checks were basic and lacked detail to confirm the care that had been delivered. End of life documentation was in place, but not all had been completed to reflect people’s individual needs and choices. There was little evidence of meaningful activities taking place. There were some records to confirm the activities undertaken, and there were plans in place to support people to access activities of their choice. We saw visitors to the service and people wearing aids to support them with their communication needs. Complaints were being managed, we saw some positive feedback had been received.

Whilst some audits had been commenced, not all of these had been completed in full. Monitoring records had not always been updated to reflect the current needs of people. Evidence was seen that team meetings were taking place; surveys had been completed. The service had been working closely with professionals to make improvements. The registered manager and nominated individual were very open and honest about the shortfalls in the service, and demonstrated their commitment to address the concerns and make the required improvements.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 8 November 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. We worked alongside the provider and local authority to monitor progress. At this inspection we found the provider remained in breach of regulations.

We carried out a targeted inspection on 10 February 2022 to ensure the Infection Prevention and Control (IPC) practice was safe. A rating was not given at that time as we did not assess all areas of the key question. We were somewhat assured at this inspection. The registered manager took immediate action to address the findings from the inspection.

This service has been in Special Measures since 8 November 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous ratings.

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 the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

Enforcement and Recommendations

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 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the safe management of medicines, the management of risks and supporting people with their nutritional needs. As well as people receiving person centred care, records, operation and oversight of the service. We also made recommendations in relation to ensuring robust systems are in place to manage safe recruitment of staff. And that the premises and the service is suitable to meet the needs of people living there, as well as a recommendation that people were able to access meaningful and regular activities of their choosing.

Please see the action we asked told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published, to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

A range of information and guidance was available to support and guide staff on the safe management of COVID-19. Risk assessments, contingency plans, policies and procedures had been developed. The guidance contained information to follow in the event of a COVID-19 positive result and isolation. The manager confirmed they would review immediately this guidance to ensure it reflected the most up to date information. The manager was new to post and had not yet been registered with the Care Quality Commission.

A recent infection control audit had been completed. This included the findings and actions required to be taken going forward. The manager had developed a system for recording of vaccinations and testing for staff. All staff had been vaccinated in line with the current government requirements.

We received concerns that professionals were not always asked for their vaccination status and lateral flow test results when they visited the service. The manager told us of the immediate actions they took to prevent this from happening in the future. They told us they had developed a new record to ensure relevant checks were completed for visitors and professionals coming to the service. A relative told us they were able to visit their family members in line with current guidance and that essential care givers guidance had been discussed with them.

All areas of the service were clean and tidy and there was plenty of PPE supplies available. The manager and staff discussed how they had managed the recent COVID-19 outbreak. Where we observed one staff member not wearing their PPE in line with guidance, the manager took appropriate action to address this.

Staff told us they had undertaken relevant training in infection prevention and control, donning and doffing and COVID-19 specific training. However, there was no records to confirm COVID-19 specific and donning and doffing training had been completed. The manager confirmed that immediate refresher training was planned and that they had undertaken observation of a number of staff completing donning and doffing.

We received positive feedback about the improvements in the service and the new manager who had recently commenced in post. There was sufficient staff in place. The manager told us there was an ongoing recruitment programme and that any gaps in duty rotas were covered by the same agency staff to maintain consistency. One relative commented, “[There are] plenty of staff around, they are the same faces. There is one or two new ones [staff] but [person] is happy, these are regular staff.” Care staff told us, “There are enough staff. We need to recruit regular staff. We are using a lot of agency but these are the same staff. We are able to do our job.”

Hollies Nursing and Residential Home Ltd provides personal care and nursing care for up to 31 people, some of whom are living with dementia. When we inspected there were 29 people living in the home.

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

The service was not being well led. The provider's quality assurance systems and audits were ineffective. There had been a lack of oversight by the provider which had resulted in a number of shortfalls that placed people at risk of not receiving proper and safe care.

People’s individual's risks including the risk of falls, choking and for the deterioration of people’s conditions were not routinely identified. This meant measures were not always in place to reduce these risks. Record keeping was generally inconsistent across the home with some records lacking in detail or not up to date.

There were significant gaps in the reporting and management of accidents and incidents. The provider had failed to notify local commissioners about incidents that had occurred. Medicines were not always managed safely across the home. Systems and processes to safeguard people from the risk of abuse were poorly developed. Staff lacked guidance to identify and report allegations of abuse, such as unexplained bruising.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We found blanket restrictions in place without first assessing people’s ability to make decisions of varying complexities.

People were not always supported by staff who had the right competences, induction and supervision to meet their needs. Staff were supporting people who challenged the service without the necessary training.

The home had experienced a high turnover of staff, and as a result was running on a high level of agency nurses and care staff. Systems for communication to staff had not been effective and up to date information to support people was not readily communicated. The home had a core group of experienced care staff who had worked hard across the pandemic to provide a degree of consistency to people.

People were protected from the risks associated with the spread of infection, including from COVID-19.

The provider had recently brought in an external interim manager who had experience of supporting homes to improve. They had prioritised a number of areas for improvement, including reviewing people's needs to ensure they received safe care and treatment.

There was a formal suspension on admissions until commissioners were assured improvements had been made. The provider had draw up an action plan for improvement, including plans to establish a robust quality assurance system designed to ensure the safe running of a nursing home.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 23/09/2020).

On 26 November 2020, we carried out a targeted inspection to ensure the Infection Prevention and Control (IPC) practice was safe. A rating was not given at that time as we did not assess all areas of the key question. We were assured of the IPC measures in place.

Why we inspected

We received concerns in relation to the management of medicines, safeguarding, staffing and the management of the home. As a result, we undertook an unannounced focused inspection to review the key questions of safe and well-led.

The inspection was prompted in part by a notification of a specific incident. Following which a person using the service died. We are undertaking further enquiries separate to this inspection.

The information CQC received about the incident indicated concerns about the management of choking and we examined those risks in general.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.

We have found evidence the provider needs to make improvement. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hollies Nursing and Residential Home Limited on our website at www.cqc.org.uk.

Enforcement

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 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to medicine management, risk management, safeguarding people from abuse, staffing, consent, quality assurance systems and governance. Please see the action we have told the provider to take at the end of this report.

Full information about the Care Quality Commission’s, (CQC), regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found the following examples of good practice.

Clear signs at the entrance followed current government guidance about visiting in care homes and helped ensure visitors understood this. Visitors had to follow an agreed procedure when entering, which included; having their temperature checked and providing track and trace information. Visitors were provided with hand gel and were offered personal protective equipment, (PPE) if they needed this.

People who had tested positive for Covid 19 had been cohorted in a separate area of the home. Staff supporting them did not work in other parts of the home. Staff breaks were staggered to support them to maintain social distancing.

There was a clear admissions procedure to be used during the pandemic. The home had followed this recently when readmitting a person from hospital.

There were enough stocks of PPE which exceeded the current recommended levels. PPE stations were seen throughout the home which helped ensure staff and visitors had access to it when required. Staff were able to don and doff their PPE safely. Staff had received training in the use of PPE, infection control and hand hygiene. Updated training had been provided which reflected any changes in the infection prevention and control, (IPC) policy.

Staff followed current guidance in relation to promoting wellbeing for people living with dementia during the pandemic. There were posters around the home which explained why staff were wearing PPE.

All staff were tested for Covid 19 every seven days. People who lived in the home were tested every 28 days and those who tested positive were retested following current guidance. People who were unable to consent to testing had been supported following the best interest decision making process.

The management team had reorganised the rotas to minimise the number of different contacts people had with staff when receiving care. Staff worked the same shift patterns and supported the same people as far as possible. Handover between shifts had been completed via Zoom between different departments.

The provider had an effective contingency plan in place to manage the impact of Covid 19 in the home. This had been implemented to good effect.

The Hollies Nursing and Residential Care Home provides personal care and accommodation for up to 31 people, some of whom are living with dementia. When we inspected there were 28 people living in the home. Accommodation is provided over two floors with lift access.

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

People were supported by staff who had been recruited safely and were trained to support people to manage risks. Medicines management had improved, and records were maintained accurately.

The providers infection control policies had been updated to reflect the additional risks posed by the Covid 19 pandemic. Staff understood and followed the procedures. The home ensured extra vigilance when accepting admissions from hospital which helped maintain peoples' safety.

Management oversight of the quality of care and care records had improved. Relatives of people living in the home told us they were confident in the new manager and identified recent improvements.

Rating at last inspection and update: The last rating for this service was requires improvement (published May 2019). There were two breaches of the regulations. The provider completed an action plan after the last inspection which showed what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of the regulations.

Why we inspected

We undertook this focused inspection to check whether the provider had followed their action plan and to confirm whether 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.

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 Good. 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 Hollies Nursing and Residential Home Limited on our website at www.cqc.org.uk.

People’s experience of using this service:

Medicines were not always being managed in line with current best practice.

Care records did not always fully document the care people required and had received.

Systems of governance and oversight were not sufficiently robust to have identified the issues we found in relation to the management of medicines and care records.

Although the provider had a system in place to ensure staff received required training, this had not been followed in the case of one recently appointed staff member.

People told us they felt safe and comfortable in the home. Staff had completed safeguarding training and knew the correct action to take to protect people from the risk of abuse. Staff had been safely recruited and there were enough staff on duty to meet people’s needs. Staff expressed a commitment to ensuring people received high-quality care.

People were cared for by staff who were kind, caring and respectful of their individual needs and preferences. Staff supported people to be as independent as possible. An activity coordinator encouraged people to engage in activities on both an individual and group basis.

People spoke positively about the way the home was run. Staff told us the registered manager had made significant improvements since their appointment in August 2018. These had resulted in an improved staff culture and better communication in the home.

Rating at last inspection: At the last inspection the service was rated requires improvement (published 18 July 2018). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve. At this inspection sufficient improvement has not been made and the provider is still in breach of regulations.

Why we inspected: We carried out this inspection based on the previous rating of the service.

We identified two continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment and good governance. Details of action we have asked the provider to take can be found at the end of this report.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Hollies Nursing and Residential Home Limited is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home is a large detached property and accommodates up to 39 older people on two floors. At the time of the inspection there were 30 people accommodated in the home.

According to CQC records, there was a registered manager in place who was also one of the owners of the service. 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. However, during our conversations with this person, they advised us they were not aware that they were registered as manager as they had thought this registration had lapsed when the manager in post at the time of the previous inspection had successfully registered with CQC in 2015. This manager had subsequently left the home in January 2018 when a new home manager had been appointed; this new manager was in post at time of this inspection and was responsible for the day to day running of the home. However, following the inspection they advised us they had tendered their resignation to the providers. The registered manager advised us they would therefore be undertaking the responsibilities of the role with immediate effect.

At the previous inspection in January 2018 we identified three breaches of regulations; these were in relation to the management of medicines, recruitment procedures and systems to monitor the quality and safety of the service. We issued a warning notice in relation to the management of medicines. We also asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective and well-led to at least good. This inspection was undertaken to check whether the required improvements had been made.

During this inspection, we found a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; this was because care plans were not always person-centred. We also identified continuing breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because systems for the safe handling of medicines needed to be further improved and the systems in place to monitor the quality and safety of the service were not effective. We are considering what action we will take in relation to this breach. Full information about the CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

This is the second consecutive time the service has been rated as ‘Requires improvement’.

Although audits were in place in relation to care plans and medicines, these had not been effective in identifying the shortfalls we found during this inspection. Although the provider took immediate action to rectify some of these shortfalls prior to the end of the inspection, it should not have been necessary for CQC to bring these matters to their attention.

Care plans were not always sufficiently personalised or detailed enough regarding people’s diverse needs. We observed an occasion during which care staff did not follow the care plan when assisting a person to mobilise. This meant there was a risk the person might come to harm.

Medicines were not stored at the correct temperature and records relating to the administration of topical creams and eye drops needed to be improved.

The call bell system did not operate safely in some rooms. This meant there might be occasions when care staff would not be able to hear and respond to the emergency buzzer. This was rectified before the end of the inspection. Staff told us this had previously been brought to the provider’s attention but no action had been taken.

Our review of records showed there had been a number of incidents of aggression from one person who lived in the home. However, when questioned the manager was unaware of these incidents and had therefore not taken the appropriate action to safeguard people who lived in the home and staff. Following the inspection, we received confirmation that the required safeguarding referrals had been made to the local authority and relevant notifications submitted to CQC.

There were limited opportunities for people who lived in the home to provide feedback on the care they received. People were unaware of their care plans and told us they had not been involved in any reviews of how their care needs were met. We were told a ‘resident of the day’ system had recently been introduced but this was not yet embedded in care planning systems. Although most people we spoke with told us they were happy with their care, one person told us staff did not have a good understanding of their particular needs. It was clear from our conversations with this person, that they had not been involved in discussions about their care with the manager or staff.

People told us they felt safe in the home and that staff were kind, caring and respectful towards them. With the exception of one incident, this was confirmed by our observations during the inspection.

Staff had been safely recruited and there were enough staff on duty to meet people’s needs. The manager told us there were ongoing difficulties with the recruitment of permanent qualified nurses but regular agency nurses where used wherever possible. Two new nurses had recently been recruited to work in the home.

With the exception of fire safety training, all staff had received training relevant to their role. New staff received an induction when they started work at the home. However, no care staff had received any formal individual supervisions since the last inspection. The manager told us they had only had the time to provide supervision to nursing staff. This meant care staff did not have the opportunity to discuss and record any training and development needs they might have.

The provider was not working within the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) to help ensure people's rights were protected. Although DoLS applications had been submitted to the local authority for people who were unable to consent to their care arrangements in the home, one person’s care records did not detail the significant restrictions which were in place within the home to protect them and others. This was rectified before the end of the inspection.

People enjoyed a varied diet and changes in their health were monitored and acted on. However, we noted one person did not have a care plan in place regarding a health condition. This matter was rectified before the end of the inspection and the person told us they did not have any concerns about the care they received.

Although the design and layout of the home was generally suited to the needs of most people who lived in the home, we noted no consideration had been given to any adaptations which might need to be made for a person who had a visual impairment. Our observations during the inspection showed all areas of the home were clean and significant improvements had been made to infection prevention measures.

During the inspection, we did not see any evidence of activities taking place. We were told this was because the activities coordinator was on sick leave. People spoken with during the inspection told us they were generally happy with the range of activities usually provided.

Staff told us they enjoyed working in The Hollies and that the manager had introduced changes which had improved the way the home was run.

Hollies Nursing and Residential Home Limited is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home is a large detached property and accommodates up to 39 older people on two floors. At the time of the inspection there were 31 people accommodated in the home.

At the time of this inspection the home did not have 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. The registered manager who was in post at the time of the last inspection had left the home in January 2018. A new manager had been in post for four weeks but they had not yet submitted an application to register with CQC.

During this inspection we identified three breaches of regulations. These were in relation to the management of medicines, recruitment procedures and systems to monitor the quality and safety of the service. This is the first time the service has been rated as Requires Improvement.

We found one of the rooms used to store people’s medicines was not clean. Another room used was not fit for purpose and people’s medicines were accessible to non-trained staff. There were no photographs or allergies noted on the medicines administration records for four people; this meant there was a risk people might be given medicines which were not prescribed for them or unsafe for them to take. Staff told us they had not done any recent training in the safe handling of medicines.

We found one person had been appointed to work at the Hollies without completing an application form. Another person’s application form only documented employment details for the previous 10 years. This meant the provider had been unable to verify people’s full employment history.

Although there were systems in place to monitor the quality and safety of the service these had not been sufficiently robust; this had led to some of the shortfalls we identified during this inspection. Some audits had not been completed for several months. Completed audits did not clearly identify who was responsible for addressing any required actions.

We received mixed feedback from people about staffing levels in the home. Staff told us they rarely had time to sit and spend meaningful time with people who lived in the home. Senior staff told us that the increasingly complex needs of people who lived in the home was placing a strain on them due to the additional responsibilities they had for the completion of paperwork, administration of medicines and contact with health professionals. A visiting health professional told us they were concerned about staffing levels in the home. They told us there was a lack of continuity of care due to the reliance on agency nurses.

We have therefore recommended the provider ensures that a recognised tool is introduced to determine how many staff are required on each shift to safely meet the needs of people accommodated in the home.

During the inspection we noted poor practice in relation to health and safety and infection control, with cleaning equipment/signs left in corridors, drinks bottles on handrails and uncovered clean incontinence pads on trolleys. We also noted the door to the sluice was unlocked. This meant cleaning materials were accessible to anyone who entered. In addition, arrangements in the laundry room did not easily support best practice in infection control measures. The manager told us they considered infection control was a key area which required improvement.

We found people’s care records did not always identify their wishes and preferences in relation to how their care needs should be met. Although care plans had been regularly reviewed, it was not always easy to find the most up to date information. This was because staff did not routinely rewrite care plans when people’s needs changed.

Staff spoken with told us that, with the exception of medicines administration and first aid, they were up to date with all required training. The manager told us that since she had started work at the service, the staff training matrix had been updated and training sessions booked in February and March 2018 with an external provider. We looked at the list of training sessions booked and noted it included fire awareness, dignity in care, food hygiene, moving and handling as well as dementia awareness. Staff told us they were aware that the manager was arranging training for everyone.

Staff had received training in the Mental Capacity Act (MCA) 2005. They were able to tell us how they supported people to make their own decisions and choices, wherever possible. The manager was aware of their responsibility under the MCA and the Deprivation of Liberty Safeguards (DoLS) to ensure that people's rights were considered and protected. Nine applications had been submitted to authorise the care arrangements for people who were unable to consent to their care in the Hollies; two of these applications had been authorised by the local authority.

People told us they felt safe living in the Hollies and had not experienced any discrimination. Staff had received training in safeguarding adults and knew the correct action to take to protect people from abuse.

People’s health and communication needs were clearly documented within their care records. Staff worked in partnership with a number of health professionals to help ensure people had access to appropriate healthcare services.

We were told there was an on-going plan of refurbishment in the home, including the redecoration of some bedrooms and upgrading bathrooms. We were shown a set of plans to improve the environment to make it more appropriate to the needs of people living with a dementia.

Staff spoken with demonstrated a good understanding of people’s diverse needs and preferences. People told us staff were kind, caring and responsive to their needs. They told us staff always respected their dignity and privacy when providing care.

People had opportunities to comment on the care they received. People spoken with told us they were aware of the complaints procedure, although they had not been required to use it. They told us they were confident action would be taken should they have cause to raise any concerns.

People told us they were satisfied with the range of activities provided. The manager told us they were currently in the process of recruiting two activity coordinators so that activities could be provided seven days a week.

The majority of staff spoken with told us they enjoyed working in the home. They told us they had found the new manager to be approachable and were confident that they would improve how the home was run. During the inspection we found the manager to be committed to service improvements as well as transparent about the shortfalls they had identified since they commenced employment at the home.

Hollies Nursing and Residential Home Limited provides accommodation and nursing and personal care for up to 39 people. There is a separate unit for seven people who are living with dementia. At the time of the inspection there were 34 people accommodated in the home.

The home is a large detached property situated in Clayton Le Moors, Accrington. The home is close to local amenities including a park, shops, library, pubs and churches. There are safe and accessible gardens and parking is available for visitors and staff.

At the previous inspection on 28 May 2014 we found the service was meeting all the standards assessed.

The service was managed by a registered manager. 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. The registered manager had been in post since April 2015 and was registered with the Commission in October 2015.

People told us they did not have any concerns about the way they were cared for. They told us they felt safe and were looked after. Visitors said, “I’m confident I can leave (my relative) here” and “I’ve never seen anything to concern me.” We observed people were comfortable around staff and good relationships between people.

Staff had an understanding of abuse and were able to describe the action they would take if they witnessed or suspected any abusive or neglectful practice. The management team were clear about their responsibilities for reporting incidents and safeguarding concerns.

People felt staff had the right level of skills and knowledge to provide them with effective care and support. They were happy with the care they received. Staff had been recruited safely and additional staff were being recruited to ensure consistent numbers of staff to meet people’s needs in a safe way. People made positive comments about the staff that cared for them. People said, “Staff are kind to me; they are lovely” and “The staff are very good. They work hard and do a good job.”

People’s medicines were managed safely. We found accurate records and appropriate processes were in place and additional training was planned for all staff who were responsible for management of medicines.

We looked at the arrangements for keeping the service clean, hygienic and maintained. A visitor said, “The place is always clean and tidy.” We found the home was clean and odour free. However we noted strong odours in the main lounge and on the dementia unit. We noted some improvements to the home had been undertaken and people were satisfied with the improvements being made. However, we found some areas were in need of attention and without a formal development plan it was difficult to determine what improvements would be made and what the expected timescales for completion would be. We made a recommendation about this.

People told us they enjoyed the meals. One person told us, “The meals are excellent.” The menus and records of meals served indicated people were offered meal choices. People were served drinks and snacks throughout the day. People’s dietary preferences and any risks associated with their nutritional needs were recorded and appropriate professional advice and support had been sought when needed. People’s healthcare needs were met and appropriate referrals had been made to specialist services as appropriate.

All people had a care plan, which had been reviewed and updated on a monthly basis. People were kept up to date and involved in decisions about care and support and some people had been formally involved in the review of their care.

There were opportunities for people to engage in suitable activities both inside and outside the home. People said, “I can have a laugh; we get on with different things” and “We can do different things; there is usually something going on. I’m happy to sit and chat with anyone here.”

People were aware how to make complaints and were confident they would be listened to. People told us they had not needed to complain and that any minor issues were dealt with informally and promptly.

A schedule of audits had only recently been introduced and the quality business officer and the registered manager had begun to carry out audits in the home to check the quality of the service. We saw copies of recently completed audits and action plans had been devised to resolve any identified shortfalls. A quality business officer had been employed to ensure regular audits were completed. This would ensure that shortfalls would be identified and appropriate action taken.

People living in the home and visitors spoken with made positive comments about the current management of the home. People told us, “The new manager seems very good and is making a number of changes” and “The place is efficiently run.”

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

We also followed up some areas in need of improvement that we found at our last inspection of 27 January 2014. The provider had sent us an action plan advising how they would improve these areas.

During this inspection we spoke with six people using the service, one visitor and the local authority. We also spoke with two care staff, one nurse, the activity coordinator and the deputy manager. We viewed records which included, three care plans and daily care records, policies and procedures, medication records, menus and records of meals served, monitoring records and equipment service records.

We considered the evidence we had gathered under the outcomes. This is a summary of what we found:

Is the service safe?

Assessments of people's ability to make safe decisions had been recorded (capacity assessments). However, the assessments did not always correspond with information in the care plans which meant it was not clear what level of support people needed. There had been no applications made under the Deprivation of Liberty Safeguards (DoLS). The acting manager said guidance around the definition of a 'deprivation liberty' was currently being reviewed and she was aware of the procedure to follow to ensure people were safeguarded.

Appropriate arrangements were in place to manage people's medicines safely. The service had noted some areas for improvement and action was being taken. One person said, 'I get my medications on time all the time'.

We found records were accurately maintained, were held securely and were kept in a way that allowed them to be located quickly when required. There were policies and procedures to support staff with their work. However, a number of these had not been reviewed since 2009.

People had access to a range of appropriate equipment to safely meet their needs and to promote their independence and comfort. Records showed that equipment was stored safely and regularly serviced and maintained.

Is the service effective?

We found the care plans contained some useful information about people's preferred routines and likes and dislikes. This should help staff to look after them properly and ensure people received the care and support they needed and wanted.

There were opportunities for involvement in suitable activities both inside and outside the home. People told us, 'There is enough going on; we get the chance to do lots of different things", "I go out with staff" and "There are different activities but I can also do what I like to do". This meant people's activities were tailored to their individual needs and preferences.

People told us they enjoyed the food. Comments included, "I like the meals; they are very nice", "We are offered a choice and they are helping me with healthier eating" and "The food is very good". Staff were aware of people's dietary preferences and were able to provide specialist diets as needed.

We were told there had been no recent complaints about this service. However, we were aware of some concerns that had not been properly recorded. Without clear records it was difficult to determine whether people's concerns had been taken seriously and whether appropriate action had been taken.

Is the service caring?

We observed staff interacting with people in a pleasant and friendly manner and being respectful of people's choices and opinions. People described staff as 'always cheerful' and 'lovely people'. People told us they were happy with the care and support they received. Comments included, "I'm looked after; staff are very good" and "It's absolutely brilliant". A visitor said, "It is well above what I expected" and 'I am confident my relative's needs are being met'.

Is the service responsive?

Regular reviews were carried out to respond to any changes in people's needs and to ensure the level of care was appropriate. A visitor told us they were kept up to date with any changes. However, the records did not clearly show people's involvement or discussions with relatives which may result in people not receiving the care they wanted.

The service had good links with health care professionals to make sure people received prompt, co-ordinated and effective care. People's health and well-being was monitored and appropriate advice and support had been sought in response to changes in their condition.

People had been encouraged to express their views and opinions of the service during meetings, customer satisfaction surveys and during day to day discussions with staff and management. There was evidence the service had listened to people's views and improvements had been made.

Is the service well-led?

The owner was also the registered manager. However she was no longer in day to day control of the home. The home was being managed by an acting manager. The acting manager was supported by the registered manager who visited the home regularly and informally monitored her practice. We were told the acting manager would be making an application to register with the Care Quality Commission (CQC).

Records and discussion showed audits of the various processes and practices were being carried out. There was evidence these systems had identified any shortfalls and improvements had been made.

We visited the service and looked at three people's care records. We found the records did not accurately reflect the care and support being given to people and that the 'audit' systems were not effective in identifying any shortfalls in the way information was being recorded. This meant people could be placed at risk of receiving inappropriate care.

In addition we noted the provider had not sent us any 'notifications' that were needed to help us monitor the service.

We asked the provider/registered person to send us an action plan indicating how, and by when, they would improve the standard of record keeping.

We found people's needs were assessed and care, treatment and support was planned and delivered in line with their individual care plan. However we found the records did not always reflect the care that was being given which meant people could be at risk of not receiving the support they needed. People told us there were opportunities for involvement in suitable activities. Comments included, "They arrange things for us to do; I enjoy most things" and "They tell me what's on and if I fancy it I go downstairs to join in".

We spoke with three members of staff. They also told us they received a range of training to give them the necessary skills and knowledge to look after people properly. People made positive comments about the staff team. These included, "Staff are lovely; they are kind and caring" and "Excellent staff".