Holmhurst 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. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They 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.

We reviewed incident records. Staff and leaders told us what action they had taken following incidents to keep people safe. However, records did not show all incidents had been reviewed by a manager. This meant the provider could not be assured all required action had been taken including notifying appropriate agencies and ensuring lessons learned were noted to reduce the likelihood of incidents repeating.

We reviewed 2 incidents where people had been assaulted by another person living in the home had not been notified appropriately.

The registered manager told us they had identified this was due to a communication error between managers. They told us how they would ensure moving forward there were robust procedures in place to ensure management oversight of incidents and any lessons learned would be identified and shared with the staff.

We observed staff listening to people and responding to their concerns. Staff knew what incidents to report and how to report them.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure the provider could take appropriate action to mitigate these risks.

The service collaborated 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.

We reviewed initial assessments for some people which covered all appropriate areas. These were used to form people’s care plans and risk assessments. There were some areas where additional information was needed. We spoke with the provider about this who took immediate action and updated these care plans and risk assessments. We spoke with staff who were able to confidently tell us how people were safely supported.

The registered manager shared with us, in detail, the process followed when a person moved into the home. This included sharing of relevant information, completing an emergency care plan and risk assessment, looking at people’s needs and the support and equipment they may need and ensuring medical support was in place. They told us they would identify any additional training staff may need and organise for this to take place.

The service collaborated with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. They did not always share concerns quickly and appropriately.

People told us they felt safe living in the home.

Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally.

The registered manager shared with us an example of when they had advocated for the people living in the home to ensure they were able to live in a safe environment.

Where restrictive practices were in place Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise, restrictions placed on people to keep them safe.

The service collaborated with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Assessments were undertaken to identify risks to people and to the care staff who supported them, a person told us they participated in this process.

Staff supported people to manage risks whilst maintaining their independence by promoting positive risk taking. Staff gave us an example of support they provided to a person, to ensure the person who at times would put themselves at risk, had support to return to the home when they chose.

The registered manager told us how they balanced risk with people’s choices and rights. They told us about other professionals who were involved to help manage risks. There were sufficient risk assessments in place in relation to supporting people who were at risk of mental health decline.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety and fire safety risk assessments were place; we observed actions from these had been completed. Records showed equipment in place had been assessed and maintained to ensure people’s safety. Any concerns with the environment were reported to the management team or appropriate person for further action.

The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

We observed during our on-site visit there were enough staff to provide safe consistent care. Rotas confirmed this.

The registered manager had a training matrix in place which evidenced most staff had completed all their induction and their statutory and mandatory training to ensure they were able to meet people's needs. Where there was training still to be completed, the provider had a robust plan in place to ensure this was achieved. The provider followed safe recruitment practices.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had an up-to-date Infection Prevention and Control (IPC) policy, and staff attended IPC training.

We reviewed cleaning schedules which were consistently completed. We observed the home had a high level of cleanliness.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences.

Staff received medication training, and their competency was checked to ensure they understood the requirements for the safe administration of medicines. Staff told us they felt well trained and confident to support people to receive their medicines safely. Staff supported and involved people to manage their medicines and followed best practice guidance for administering medicines.

The staff team were proactive at reporting any changes to people’s medicines promptly. The registered manager told us, during people’s annual health reviews, their medicines would be reviewed, or this would happen sooner if needed.