Holywell Nursing 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. This was the first assessment for this service under the new provider. At this assessment we have rated this key question good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A learning process had recently been implemented across the home and was being imbedded.

Staff told us concerns were listened to and improvements made. One staff member said, “We have fed back about needing more staff and this was implemented” and described the management as approachable and responsive.

When we found issues during our visits, such as incorrect mattress settings or inconsistent recording, managers took immediate corrective action, demonstrating a positive approach to learning and safety improvement.

People’s risks were assessed before moving in, and staff understood their needs. The provider ensured pre‑admission assessments took place. These were carried out by the manager or by nursing staff to confirm the service could meet a person’s needs.

Staff knew how to seek professional support when needed. However, people were not always able to see their GP in person; GPs had diagnosed people ‘over the phone’ or by people sending photographs to them. The management team had raised this concern with the GP practice, but this had not yet been resolved.

People said they felt well supported, with one relative stating staff “Nip [health concerns] in the bud”, preventing hospital admissions. Records for some areas needed improvement to ensure risk information was consistently captured, although managers acted promptly when this was raised during our visits.

People told us they felt safe living in the home, with one person stating, “I absolutely feel safe. I have no concerns”. Relatives had confidence in care staff and described them as kind and attentive. People said if they raised any concerns, such as agency staff not caring for them properly, their concerns were addressed and dealt with appropriately.

Staff had received safeguarding training and understood what to look for and how to report concerns. Staff knew how to raise concerns outside of the organisation (‘whistle blowing’). One staff member said, “I would report anything I see to my line manager. If I wasn’t listened to, I would go to CQC or Somerset safeguarding."

The management team and care staff worked with people and their relatives to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff supported and encouraged people’s independence by promoting positive risk taking.

People’s care records included information about individual risks and how staff should work to minimise risks to people. For example, risks around malnutrition, mobility, choking, equipment use, skin integrity and falls were assessed and regularly reviewed. We saw staff worked in a safe way, in line with people’s risk assessments.

Significant improvements to the environment were needed to ensure people's comfort, privacy and safety. Work had already started to address these issues.

The environment required improvement, and the management team acknowledged this. There were worn carpets, equipment cluttering the first‑floor lounge and poor‑condition bed bumpers which posed infection‑control and safety risks. Work to refurbish bedrooms and corridors had already begun, and staff confirmed they were kept informed about upcoming improvements.

A wide range of health and safety checks had been introduced by the new member of staff responsible for maintenance to ensure people’s safety. They had many years of experience of working in care homes and had won an award at their previous home. They had introduced many checks such as fire safety, electrical safety, hot water and gas safety checks. We were told none of these checks were in place before they started working in the home.

The management team took prompt action on environmental hazards we raised during inspection, but the home still needed sustained improvement to ensure people were provided with a safe and homely environment.

People were supported by enough staff to meet their needs, and both staff and people described the team as caring and supportive. While some people said there could be short delays in care at times, people told us they felt safe and well cared for, with one person commenting, “I love it here. They [staff] are so good; there are enough staff.” One staff member told us, “The team is good, and the manager is very supportive.”

Staff training, support and recruitment had been significantly improved by the new management team. Staff were well supported and well trained. Formal supervision meetings, probation reviews and appraisals with staff had been introduced. One staff member said, “I have supervisions 3 monthly. I can raise issues and if I raise something it gets followed up. I have asked for more responsibility [in my role] and was promoted.”

Regular staff meetings were held. Records of meetings showed these were well attended, covered a range of topics and staff were encouraged to raise any issue they wished to discuss.

People were supported by staff who had been recruited safely. Appropriate checks were carried out on all new staff to ensure they were able to work in the UK, of good character and safe to support vulnerable people. This helped to ensure people’s safety.

People were not fully protected from the risks of infection as infection control arrangements required improvement.

People generally described the home as clean. One person told us, “I can’t knock the cleanliness or laundry.” However, we identified some infection control risks during our visits, such as breached bed bumpers and flooring which needed replacing. These issues were discussed with the home manager who arranged for bed bumpers to be replaced immediately. Improvements to the environment were ongoing but were acknowledged as being needed.

Staff demonstrated a good understanding of personal protective equipment (PPE) use and cleaning practices. One staff member told us, “We have enough aprons, gloves and cleaning products."

People generally received their medicines safely, although some improvements were needed. People told us their medicines were usually on time, with one commenting, “They [nurses] are very good with my medication. I get it on time. I know what I am taking and why.” We observed nurses administering medicines competently and explaining medicines to people.

There were suitable arrangements for ordering and disposal of medicines, including those needing increased controls. The storage of most medicines was secure, except for a food and beverage thickener. Once brought to the attention of staff, the product was stored securely.

Temperature monitoring was carried out to make sure medicines would be safe and effective.

There were some improvements needed to the information about medicines prescribed to be taken ‘when required’. For example, the reason it was given, the exact time and actual dose administered and the outcome (whether the medicine was effective).

Staff had training and competency checks to make sure medicines were safely managed.