Hollin Knowle Residential Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.
At our last inspection we rated this key question as good. At this inspection the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.
The provider was in breach of the legal regulations relating to governance.
 

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.
The provider did not demonstrate an understanding of the requirement to ensure the current CQC rating of Hollin Knowle residential care home was on prominent display in the care home. It is a requirement that CQC ratings be displayed on posters at registered premises no later than 21 calendar days after we have published them on our website. Providers are required to be transparent in respect of their CQC ratings and ensure they are displayed to help people to find out about the quality of the care service.
Staff told us they understood how their role helped in achieving that compassionate culture. A staff member told us, “From what I have seen, staff are always kind and caring towards people, ensuring they are treated with respect, dignity, and reassuring and supporting people to meet their individual needs.’
Staff received training to ensure they understood equality, diversity and human rights, and so they understood the need to prioritise safe, high-quality, and compassionate care. For example, as staff member told us, “Out of the care homes I have worked in, this is by far the best one in respect of how the residents always come first. It is a happy, small, family home. Personally, I would be happy for my children to put me in here if I'm fortunate enough to reach old age. I’d be happy for a family member to live here, as I know they'd be looked after with genuine kindness and care.”.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.
The provider did not demonstrate an appropriate level of understanding of environmental risks in care home premises, their potential impact on people, and the routine safety measures required to mitigate those risks. For example, the provider had not identified their fire safety, water safety, cleanliness and hygiene processes and records were deficient. This meant there was an increased risk that people may come to harm.
The provider did not demonstrate an appropriate level of understanding of safe staff recruitment processes and the need to ensure the necessary pre-employment checks were always carried out and appropriate records of those checks kept. This meant there was an increased risk of unsuitable people being appointed to work in the care home.
During the inspection the provider showed the inspector a set of property risk assessment documents which they told us they had in place at the care home. However, when reviewed, elements of those risk assessment documents were found to be generic and not relevant to the care home. The provider had not recognised their risk assessment documents were not appropriate to the operation of a registered care home.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
The provider encouraged staff to raise concerns and promoted the value of doing so. When concerns were raised, the registered manager investigated sensitively and confidentially.
A staff member told us, “The registered manager has always been approachable and supportive. I've always felt comfortable asking for advice or raising concerns, and I feel that my opinions are listened to and respected.”
The registered manager told us that when something goes wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again.
 

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.
The provider had policies and procedures for inclusion and diversity within the workforce. For example, recognising people’s protected characteristics and ensuring appropriate measures were in place to support these. Protected characteristics are a set of nine characteristics that are protected by law to prevent discrimination. For example, discrimination based on age, disability, race, religion or belief, and sexuality.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
The provider did not have clear and effective governance, management and accountability arrangements in place. The registered manager did not demonstrate an understanding of the governance and quality monitoring requirements of their role and responsibilities. For example, there were minimal quality audit processes in place which meant quality and safety issues were not always identified in a timely manner. This meant people were at an increased potential risk of harm.
The registered manager had not implemented an organised and effective process or system for monitoring the environmental safety of the care home. Where appropriate systems and processes were in place they were not being consistently used. For example, the provider had a fire logbook in place, but it was not being completed with the necessary information to evidence routine fire safety checks were regularly being carried out, or fire safety system defects rectified in a timely manner.
The registered manager undertook to carry out safety improvement actions swiftly, once explained to them by the inspector. But the provider’s own governance and quality monitoring systems should identify safety issues without having to rely on external agencies to point them out. This failure to pro-actively determine service improvements, from their own quality monitoring systems, was an issue we had previously raised with the provider at our last two inspections. At this inspection we found the provider had continued to fail to demonstrate their ability to proactively and consistently ensure sustained, timely and continued service improvement. This meant people were at an increased risk of potential harm.
The registered manager ensured that necessary notifications to external agencies, such as the Local Authority safeguarding team and the Care Quality Commission, were submitted in a timely manner.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.
The registered manager understood the importance and benefits of working alongside other professionals. The registered manager confirmed they collaborated with external safeguarding teams in the investigation of serious accidents or incidents. Staff also worked in partnership with external health care professionals and community health services to ensure people received effective care.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.
The provider did not demonstrate an understanding of how to make improvement happen. The provider did not have an appropriate continuous improvement plan in place. This meant there was no organised process in place to track improvements which had been identified by the registered manager, staff, or external agencies. The provider’s approach to learning and improvement was therefore inconsistent and there was a lack of evidence to demonstrate required improvements had been made.
The provider did not have effective processes established to ensure learning happened when things went wrong. For example, a risk assessment had been carried out by an external contractor in respect of premises water safety. The risk assessment had stated the areas of safety deficiency and identified the routine mitigation actions which were required to reduce those risks to an acceptable level. The provider had not effectively implemented those safety recommendations and did not demonstrate an understanding of the risks involved or that they had learned the importance of addressing them. This meant people were at an increased risk of potential harm.