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Holbeche House Care Home Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 21 August 2019

About the service

Holbeche House is a residential care home providing personal and nursing care for up to 49 older people, some of whom live with dementia. At the time of the inspection the service was supporting 42 people. The care home accommodates people in one adapted building which is split into two units. One unit supports people with nursing needs and the second unit supports people that live with dementia.

People’s experience of using this service and what we found

People did not receive their medicines as prescribed and management of medicines placed some people at risk of harm. Risks to people were not consistently well managed and left people at risk of harm. There was not enough staff to meet people’s holistic needs.

People told us they felt safe when supported by staff. Staff wore gloves and aprons to ensure they protected people from cross infection. Lessons were learned from any incident and accidents that had occurred in the service.

Staff had completed training in relation to the Mental Capacity Act but lacked the knowledge about which people had authorisations in place. The environment on one unit was not dementia friendly and homely and lacked signage to enable people to orientate themselves. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People accessed healthcare services to ensure they received ongoing healthcare support.

People were supported by staff who were caring, but the provider's systems and processes did not support them to consistently display their caring values. People were given some choices and were involved to make daily decisions around their care. People on occasion were not always treated with dignity.

People did not have meaningful activities to occupy them on a daily basis. People had care plans in place which provided staff with information about their needs and preferences and how they would like these to be met. However, these were not always updated following incidents that had occurred. Records did not reflect the daily support provided to people. A complaints procedure was in place and people and their relatives knew how to raise concerns and felt confident these would be addressed.

The systems and processes in place were not robust to enable the provider to identity where areas for improvement were needed. Where improvements were identified timely action was not taken to address these. The registered manager was described as approachable, open and transparent in the way they managed the service.

Rating at last inspection

The last rating for this service was good (published 8 February 2017).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to the management of medicines and the overall governance of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

For more details, please see the full report which is on the CQC website at

Inspection areas


Requires improvement

Updated 21 August 2019

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 21 August 2019

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 21 August 2019

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 21 August 2019

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 21 August 2019

The service was not always well-led.

Details are in our well-Led findings below.