Hollin Knowle Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question as good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.
The provider was in breach of the legal regulations relating to safe care and treatment, premises and equipment, and ensuring that fit and proper staff were employed.
 

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.
Necessary improvements were not always made when things went wrong. There was limited use of systems to record and report safety concerns, incidents and near misses. For example, the registered manager used a generic accident book, designed to record staff workplace accidents, to record incidents involving the people living at the care home. People’s incident records were not appropriately detailed and there was no evidence they were reviewed by the registered manager. This meant people were potentially at an increased risk of harm due to previous incidents not being reviewed and risk mitigations identified.
Safety concerns were not always consistently identified or addressed quickly. There was not always a culture of openness, transparency, and learning from events which had potentially impacted people’s safety in the care home. For example, a roof leak had affected parts of the care home. Emergency repairs had been carried out, but a permanent resolution of the issue had not been implemented. The registered manager told us they had no clear timescale for when the work would commence. This meant people were at an increased risk of being in a poor living environment in parts of the care home.

There was not always a willingness to act quickly to put things right, learn and improve. For example, in 2021 the registered manager had commissioned a risk assessment of the water services in the care home. The risk assessment rated the water services at the care home as very high risk and identified a list of requirements which were, ‘Urgent and important actions and directly relate to a loss of control and exposure to unacceptable levels of risk.’ The registered manager had not acted to address those identified high priority safety issues. This meant people were at an increased risk of potential harm from issues relating to water safety.
People and staff told us they felt comfortable in raising concerns about their care with the provider. They told us they would be treated with compassion and understanding and would not be blamed or treated negatively for raising concerns.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.
The provider had an appropriate process for new referrals, obtaining a copy of the person’s initial assessment, and then carrying out their own assessment of need, before deciding whether they would be able to provide support. There was a paper-based care record system in place, which care staff had access to. This helped ensure people’s care was provided in a planned, responsive and organised way.
People, and their relatives where appropriate, were listened to by the provider’s staff when their initial care plans were being created. This helped ensure people were supported to receive continuity of care when they started receiving care from this service.
 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.
People told us they felt comfortable when staff interacted with them. Staff used respectful language when describing people and their care needs. The provider had a comprehensive safeguarding policy and procedure in place.
People also had access to people outside of the service with whom they could raise concerns about their safety if necessary. For example, social workers, other visiting health care professionals, and family members. The provider co-operated with safeguarding enquiries carried out by the Local Authority.
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
People’s individual risks were assessed, and details were available to care staff in people’s care plans. Care plans were amended when people’s needs changed or when they changed how they wanted to receive care from staff.
Staff knew the people they supported well and were aware of the symptoms and cues which might indicate they were becoming unwell or distressed. Staff told us how they supported and encouraged people, enabling them to make their own decisions, rather than trying to control people.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure that equipment, facilities and technology supported the delivery of safe care.
People were cared for in an environment which was not always safe. The provider’s arrangements to monitor the safety and upkeep of the care home premises were not effective. For example, there were deficiencies in the safety measures in place to protect people from encountering potentially scalding water. There were also deficiencies in safety measures to prevent legionella bacterial infections. Legionella bacteria can cause Legionnaires' disease which is a potentially serious lung infection people can get from inhaling droplets of water.

Some people’s bedrooms had wardrobes which were not secured to the wall and so posed an increased risk of toppling over and potentially injuring people.
Some first-floor windows were not fitted with window opening restrictors, this meant there was an increased risk of people coming to harm as a result of falling from height.

Routine checks of the fire detection and fire prevention systems and equipment were not being carried out at the intervals specified in the provider’s fire risk assessment document. Appropriate records of these checks were not being created. This meant there was an increased risk of a fault in the care home fire safety system not being noticed or rectified swiftly. For example, during the site visit it was observed that a smoke detector had been removed in the lounge, with no record made in the fire logbook, or any risk mitigations put in place. This was raised with the registered manager who then arranged for a temporary additional smoke alarm to be installed in that room.

People were at an increased risk of being burned because of encountering hot surfaces if they fell against a radiator, as not all radiators had safety covers fitted, and some radiator covers were not securely fastened to the wall.

A person’s bedroom ensuite toilet wall was observed to show signs of damage caused by damp. We also found evidence of black mould on the wall and ceiling of a communal toilet room. This meant there was an increased potential risk of harm as, in some cases, the respiratory effects of damp and mould can cause serious illness. The registered manager told us they would address the damp issue straight away.

Some areas of the care home were in poor decorative condition. The registered manager told us the care home was part way through redecoration and refurbishment work.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.
The registered manager did not have an effective programme of appropriate staff training in place. The provider had a staff training matrix document, which recorded the training care staff had received, and the dates when refresher training was due. The provider’s training matrix demonstrated not all staff had received the training the provider had identified as being necessary, and refresher training was not being received at the required intervals. For example, the provider’s safeguarding policy stated all staff should receive safeguarding training annually, but their training matrix stated they should receive refresher training every 3 years. In any event, the provider’s training matrix evidenced neither annual nor 3 yearly safeguarding refresher training was happening consistently.
Care staff had not received any training in respect of supporting people who have a learning disability or autistic people. Since 1 July 2022, all CQC registered health and social care providers have been required to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people with a learning disability. This should be at a level appropriate to their role. A staff member also told us, “I think we should have ongoing training in caring for people with more complex needs, such as advanced dementia and visual impairment. That would be beneficial given the people we support.”
The provider did not have robust and safe recruitment practices in place. We reviewed a sample of care staff recruitment records and found gaps in the information the provider held about staff members’ previous work history and right to work in the United Kingdom. We also found references from previous employers were not always obtained by the provider. This increased the potential risk of unsuitable people being recruited by the provider to care for people at the care home.
The registered manager ensured enough staff were rostered on duty to meet people’s assessed care and support needs. A staff member told us, “We always have enough staff on shift. If for some reason a staff member cannot come in, due to illness, then management try to arrange cover whilst staff on duty work together to ensure essential care is provided.”
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.
The provider did not have effective processes in place for assessing and managing the risk of infection. For example, the registered manager did not understand the water system control measures necessary to reduce the risk of Legionella infection. Similarly, the provider’s processes had not identified areas of black mould in a communal toilet room or damp in a person’s ensuite bedroom toilet. Damp and mould within the home can produce allergens, irritants, mould spores and other toxins that are harmful to health. Even if visible mould is not present, dampness alone can increase the risk of health problems.
Not all areas of the care home were being kept clean and hygienic, and the registered manager did not have effective processes in place for monitoring whether cleaning tasks had been carried out regularly and to an acceptable standard.
Waste management arrangements were not always effective. On the three site visit days, the external clinical/hazardous waste bin was observed to be overflowing and the lid not closed. That created an opportunity for the clinical/hazardous waste to be interfered with by rodents and birds and increased the risk of a potential spread of infection.
The provider’s infection control policy was in line with current relevant national guidance but was not being followed consistently in practice. The policy document stated all staff complete infection prevention and control refresher training annually. But the provider’s staff training matrix stated care staff should receive infection control training every 3 years. Despite this, the training matrix evidenced staff were not receiving either annual or 3 yearly refresher training consistently. This increased the risk of infection spreading within the care home due to a potential lack of staff understanding of the preventative measures needed.
The provider ensured their staff had access to the necessary personal protective equipment (PPE) to support effective hygiene and infection prevention. A staff member told us, “We have enough equipment and PPE to do our work safely and to keep residents comfortable, safe and protected from harm”
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.
People’s medicines were appropriately prescribed, supplied, stored, and administered in line with the relevant legislation.
People’s prescribed medicines were regularly reviewed by external medical professionals as part of their complex individual health care support.
The provider had appropriate arrangements in place for the safe management, use and oversight of controlled drugs. People had up-to-date information about their medicines available in their care plans and the provider’s medicine records. The provider worked with people to ensure they had the necessary prescribed medicines available to them.