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Archived: Holme Bank Residential Home Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 14 February 2019

The inspection site visit took place on 04 and 05 September 2018 and was unannounced. At the last inspection completed 09 November 2016 the provider was meeting all legal requirements and the service was rated as ‘good’. At this inspection we found widespread and significant concerns about the care being provided with multiple legal requirements not being met.

Holme Bank is a ‘care home’. People in care homes receive accommodation and 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 accommodates up to 20 people in one adapted building. At the time of our inspection there were 15 people living at the service. Most of the people living at the service were older people living with dementia.

The provider had failed to ensure a registered manager was in post. 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. A manager remained registered with CQC although they had left their post in 2017. A new manager had been appointed although had left prior to registering with CQC. An ‘acting manager’ was in place during the inspection who had recently taken on this role.

There were widespread and significant concerns identified about the management of risk within the service. People were exposed to multiple risks including those connected with choking, challenging behaviour and skin integrity without appropriate mitigation being in place. People were not protected from potential abuse due to safeguarding incidents not being recognised and reported. People were exposed to the risk of harm due to the poor management of medicines within the service.

People were not supported by sufficient numbers of suitably skilled and experienced care staff. There were widespread issues with the lack of training and supervision of care staff.

People’s rights were not being upheld as the Mental Capacity Act (MCA) was not being used effectively. Decisions were being made about people’s care without the required legal steps being taken under this Act.

People’s nutritional needs were not always met. Advice and intervention from healthcare professionals was not always sought in a timely manner which exposed people to the risk of harm.

While people recognised individual staff members as being kind and caring, they did not always feel the support they received was caring. We found the lack of staff numbers, training and supervision resulted in care standards being poor. Support provided was not always caring. People’s dignity was not always upheld and their independence was not actively promoted.

People were not always fully involved in the planning of their care. People’s needs were not always appropriately assessed and the care and support people received did not always meet their needs. People did not have access to sufficient leisure opportunities.

People’s complaints were not always actively sought and listened to. These complaints were not always responded to appropriately and they were not used to drive improvements across the service.

People were being supported by a staff team who were demoralised and under supported. The culture within the service had become closed and care staff had become afraid to speak out about concerns they had.

People were exposed to significant risks due to the inadequate governance and management arrangements in place. We found there were no auditing and quality control systems in place which had resulted in the provider not identifying the significant issues present within the service.

Due to concerns being identified during the inspection about people’s immediate safety, we contacted the local safeg

Inspection areas

Safe

Inadequate

Updated 14 February 2019

The service was not safe.

There were widespread and significant concerns identified about the management of risk within the service.

People were not protected from potential abuse due to safeguarding incidents not being recognised and reported.

People were exposed to the risk of harm due to the poor management of medicines within the service.

People were not supported by sufficient numbers of suitably skilled and experienced care staff.

Effective

Inadequate

Updated 14 February 2019

The service was not effective.

There were widespread issues with the lack of training and supervision of care staff.

People’s rights were not being upheld as the Mental Capacity Act (MCA) was not being used effectively.

People’s nutritional needs were not being met. Appropriate support from healthcare professionals was not always sought.

Caring

Inadequate

Updated 14 February 2019

The service was not caring.

People did not always receive support in a kind and caring way.

People’s dignity was not always upheld and their independence was not actively promoted.

Responsive

Inadequate

Updated 14 February 2019

The service was not responsive.

People were not always fully involved in the planning of their care.

People’s needs were not always appropriately assessed and the care and support people received did not always meet their needs.

People did not have access to sufficient leisure opportunities.

People’s complaints were not always responded to appropriately.

Well-led

Inadequate

Updated 14 February 2019

The service was not well-led.

People were being supported by a staff team who were demoralised and under supported.

The culture within the service had become closed and care staff had become afraid to speak out about concerns they had.

People were exposed to significant risks due to the inadequate governance and management arrangements in place.