• Care Home
  • Care home

Archived: Holly Court Care Home

Overall: Good read more about inspection ratings

8 Priory Grove, Off Lower Broughton Road, Salford, Greater Manchester, M7 2HT (0161) 708 0174

Provided and run by:
Four Seasons (Bamford) Limited

Important: The provider of this service changed. See old profile
Important: The provider of this service changed. See new profile

All Inspections

11 December 2020

During an inspection looking at part of the service

Holly Court Care Home is registered to provide personal care and accommodation for up to 25 adults. At the time of the inspection there were 21 people residing at the service. The home is situated in a residential area of Salford. It specialises in care for older people and people living with dementia.

We found the following examples of good practice.

Checks on whether visitors had symptoms or had tested positive were in place; the provider asked visitors to declare whether they had been in contact with anyone displaying COVID-19 symptoms or who had tested positive. Visitors had their temperature taken and appropriate hand hygiene and wearing of PPE was promoted on entry to the home.

People were isolating safely in their rooms and the provider had followed correct procedures to ensure any restrictions and social distancing were in people’s best interests.

The management team had worked closely with colleagues across health and social care, such as the local infection control team, to ensure they were following the most up to date guidance. Staff wore and disposed of PPE appropriately and used hand hygiene stations regularly. We observed continuous cleaning during our visit.

Robust risk assessments were completed, making it clear how staff could reduce the risk of transmission of COVID-19. Where risks had been identified for staff and people, clear guidance on managing the risk had been recorded. Staff had received tailored COVID-19 training and competencies in donning and doffing PPE had been carried out. Infection control audits were comprehensive and had been completed regularly.

Further information is in the detailed findings below.

11 March 2020

During a routine inspection

About the service

Holly Court Care Home is registered to provide personal care and accommodation for up to 25 adults. At the time of the inspection there were 24 people residing at the service. The home is situated in a residential area of Salford. It specialises in care for older people and people with dementia.

People's experience of using this service and what we found.

People and their relatives told us they felt safe. The provider had effective safeguarding procedures and staff felt confident raising concerns. People told us their medicines were being managed safely and comprehensive assessments of need and care plans were undertaken. Feedback about the service from people and their relatives was positive.

The environment was clean, welcoming and well maintained. People told us staff were kind and caring and treated them with dignity and respect. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff told us they enjoyed their jobs and felt supported by the current management team. Audits were taking place to ensure staff provided people's care safely and in the way that they preferred. The registered manager had a visible presence and had a good oversight of people’s needs.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 25 July 2017)

Why we inspected

This was a planned inspection based on the previous rating.

29 June 2017

During a routine inspection

This inspection took place on 29 June 2017 and was unannounced.

Holly Court is a small residential home supporting the care needs of people living with various types of dementia. The home can accommodate up to 25 residents. The home is situated in Salford and is close to local amenities and bus routes. The home is owned by Four Seasons (Bamford) Limited.

At the time of our inspection there were 24 people living at Holly Court.

At our last inspection in January 2015, the service was rated as Good. At this inspection we found the service remained Good.

The service had a registered manager. 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.

People told us they felt safe living at Holly Court. Staff received safeguarding training and knew how to keep people safe and raise concerns if they suspected someone was at risk of harm or abuse.

People had comprehensive risk assessments which were reviewed and updated timely to meet people’s changing needs. This ensured staff had access to the relevant information and guidance to mitigate risks.

Staffing levels were based on the dependency of people living at the home. People, relatives and staff told us, there were sufficient numbers of staff on duty to meet people’s needs.

The management of medicines was safe. There were appropriate arrangements in place to ensure that medicines had been ordered, stored, received and administered appropriately.

The service had a training matrix to monitor the training requirements of staff. Staff received appropriate training, supervision and appraisal to support them in their role. Appropriate documentation was maintained when these sessions had taken place.

People were supported in line with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS), with people encouraged to make decisions and choices about the care they received.

People's consent to care and treatment was sought prior to care being delivered, with written consent to people having their photograph taken captured within care plans.

People had access to sufficient amounts to eat and drink, at times that suited them. Staff responded appropriately where people were deemed to be at risk of choking or weight loss, making referrals to other health professionals in a timely manner.

People continued to receive care and support from staff that were kind, caring and compassionate. People were treated with dignity and respect and had their independence promoted by staff as much as possible.

Care plans were person centred and tailored to meet people's individual needs. Care plans contained person centred information about people’s likes, dislikes, preferences and choices.

A variety of activities were provided to people living at the home. The feedback we received was that there was enough for people to do to keep them occupied.

The provider had a complaints procedure in place and people felt confident in raising concerns or complaints to staff and the registered manager.

The registered manager and provider carried out regular audits of the home. We saw areas of improvement were identified and shared throughout the staff team to demonstrate action had been taken in a timely manner. Feedback of the home was sought and used to drive continued improvements.

27 July 2016

During an inspection looking at part of the service

This was an unannounced inspection carried out on the 27 July 2016, in response to concerns we had received regarding staffing levels and the management of falls at the home. This report only covers our findings in relation to those issues. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Holly Court Care Home on our website at www.cqc.org.

Holly Court is a small care home supporting the care needs of people with various types of dementia. The home can accommodate up to 25 people. The home is situated in Salford and is close to local amenities and bus routes.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

Both visitors to the home and staff we spoke with consistently told us that staffing levels were sufficient to meet people’s needs.

Staffing rotas indicated that staffing levels were consistently maintained.

The home used a dependency tool known as ‘CHESS,’ which stood for Care Home Equation of Safe Staffing. The purpose of the tool was to identify each person’s dependency needs, which then enabled the service to calculate the numbers of care staff required.

During the day there were two members of staff covering each floor, supplemented by the activity coordinator and the registered manager. At night time there was one member of staff on each floor with a floating member of staff to provide assistance where required.

The registered manager told us that people who used the service were mostly mobile and some wandered both corridors and the garden area in good weather. We found there were sufficient numbers of staff on during our inspection to support people who used the service.

On the day of our inspection, people who used the service were using the garden area together with visiting relatives. The garden was enclosed and was a pleasant and peaceful area for people to use. We noticed that some roots from established trees presented a trip hazard on the grass area, however tables and chairs were located in that area.

The pathway and patio area was level and well maintained with a path ascending a slight gradient to the entrance into a sister home. The manager told us that a hand rail had been recently installed along the length of the path to provide support for people.

We looked at a sample of four care files to understand how the service protected people against falls. Each care file covered people’s mobility needs and contained risk assessments and care plans to address people’s needs. Risk assessments which identified people as ‘high risk of falls’ provided staff with instructions on the level of support and supervision required.

When a fall had occurred, the service undertook an investigation into the circumstances of the incident, which included details of the fall, notification of family members and any lessons learned from the incident.

We looked at internal audits and ‘falls studies’ undertaken by the service. This recorded action taken for specific people who had experienced more than two falls. This included interaction with other professionals and whether a nursing care assessment was required, more appropriate walking aids or medication reviews.

We also looked at the home’s Policy for Falls Management, which was dated 17 May 2016, which provided guidance to staff and included strategy, risk assessments, incident reporting and investigations and monitoring.

The registered manager told us that they had arranged a Postural Stability Strength and Balance Training course for all staff commencing in August 2016. The aim of this training was to introduce balance and strength exercises to staff so they could deliver a series of falls prevention exercises to improve balance and help reduce the risk of falls amongst people residing at the home.

03 July 2015

During an inspection looking at part of the service

We carried out an unannounced comprehensive inspection of this service on 22 January 2015. During that inspection we found one breach of Regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. After that inspection, the provider wrote to us to tell us what action they had taken to meet legal requirements in relation to the breach of regulation.

As part of this focused inspection we checked to see that improvements had been implemented by the service in order to meet legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Holly Court Care Home on our website at www.cqc.org.uk.

This inspection was undertaken on 03 July 2015 and was unannounced. We found the provider had made improvements and was now meeting the requirements in relation to the breach we had found.

Holly Court is a small care home supporting the care needs of people with various types of dementia and confusion. The home can accommodate up to 25 residents. The home is situated in Salford and is close to local amenities and bus routes. There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

At our last inspection we found that the registered person had not protected people from the risks associated with the safe administration of medication. During that inspection we found vulnerable people were exposed to risk, because the service did not have appropriate arrangements in place to manage medicines safely. We found records supporting and evidencing the safe administration of medicines were not always completed. We also found that one medicine had not been stored in line with manufacturer’s instructions as it required cold storage and that staff had failed to record fridge temperatures consistently. This was a breach of Regulation 13 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which related to the safe administration of medicines.

During this inspection we found the provider was now meeting the requirements of the regulation. We looked at a sample of nine medication administration records (MAR) charts, which contained no omissions or signature gaps. We found all medicines were stored securely and at the correct temperatures in line with manufacture’s guidance. We noted that fridge temperatures were now accurately recorded by staff. We also looked at daily audits undertaken by staff and twice monthly audits undertaken by the registered manager.

22 January 2015

During a routine inspection

This unannounced inspection was carried out on the 22 January 2015.

Holly Court Care Home is situated in Salford and provides accommodation and support for people with various types of dementia. Accommodation comprises of 25 single en-suite bedrooms over two floors. At the time of our inspection there were 25 people living at the home. There is parking for several cars to the front of the property. The home is close to local amenities and bus routes.

Holly Court had a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

At the last inspection carried out in April 2014, we identified concerns in relation to safe recruitment procedures of staff, we found not all people were adequately protected against risk and some people did not have suitable care plans in place to meet their needs. As part of this visit we checked to see what improvements had been made by the home to address these concerns.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We looked at how the service managed people’s medicines and found that not all aspects of the service were safe. We found records supporting and evidencing the safe administration of medicines were not always completed. This meant it was not possible to tell if a course of treatment had been taken correctly. In line with good practice, it is essential that staff involved with the administration of medicines maintain an accurate record of which medicines have been administered and by whom.

Whilst observing staff administer medicines to people who used the service, we found that one medicine had not been stored in line with manufacturer’s instructions as it required cold storage.

When we checked the medication fridge temperatures, we found several gaps in records. This meant staff were unable to ascertain if the medication had been stored at the correct temperatures and was safe to use.

This is a breach of Regulation 13 of The Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2010, because the service did not have appropriate arrangements in place to manage the safe administration of medicines.

People who used the service and visiting relatives told us they believed they or their loved ones were safe at Holly Court Care Home. One person who used the service told us; “I feel very happy and perfectly safe here.” A visiting relative said “No concerns, very happy, X is safe here. X seems very happy here.”

As part of our inspection, we checked to see how people who lived at the home were protected against abuse. We found the home had suitable safeguarding procedures in place, which were designed to protect vulnerable people from abuse and the risk of abuse.

During our last visit we identified concerns about the safe recruitment of staff. We looked at a sample of five staff files and found each contained records, which demonstrated that staff had been safely and effectively recruited.

During our last visit we found some people were not adequately protected against risk. We looked at a sample of five care files of people who used the service and found there was a comprehensive range of risk assessments in place designed to keep people safe from harm.

On the day of our inspection, there were 25 people living at the home divided between the ground and first floor. We found there were sufficient numbers of staff available including care staff and ancillary staff.

Holly Court Care Home was part of the Pearl Project, which was a specialised dementia care programme developed by the provider. On the ground floor of the home, we found themed corridors had been introduced to help orientate people and provided sensory stimulation. Themes were artistically exhibited in corridors with visual clues.

A comprehensive schedule of e-learning training was undertaken by all staff, which we verified by looking at training records. We looked at supervision and annual appraisal records and spoke to staff about the supervision they received. Staff told us they received support and training to undertake their roles effectively.

During our last inspection we found not all people had an appropriate care plan in place to meet their needs. We found care files reflected the current health needs of each person who used the service. These included a needs assessment and detailed individual care plans which provided direction to staff on the type of support each person required.

The Care Quality Commission has a duty to monitor activity under the Deprivation of Liberty Safeguards (DoLS). We found all staff demonstrated a good understanding of the legislation and all had received training, which we verified from looking at training records.

We found the meal time experience to be relaxed and well organised. We observed staff washing their hands and asking people whether they wanted to wear an apron during the meal time. We saw people being asked what they wanted to eat and were offered a choice of foods. For people who had difficulty communicating, we saw picture cards being used to demonstrate the choices available.

We observed people were clean and nicely dressed. We found staff were kind and attentive and engaged with people in a pleasant manner.

Visiting relatives told us they were regularly consulted about the needs of their loved ones and felt confident in raising any issues with the management, which would be listened to.

The home was part of the North West End of Life Care Programme known as Six Steps to Success. Three members of staff had received training in this end of life care programme, which enabled people to have a comfortable, dignified and pain free death.

We found people’s needs were assessed and care and support was planned and delivered in accordance with people’s wishes following a needs assessment and included religious and spiritual needs.

The service employed an activities coordinator and maintained individual journals for people detailing their involvement in any activity. Events organised included games, visits and pub lunches, themed parties such as Halloween, baking, craft and cinema sessions that included popcorn. During the afternoon we observed a quiz session which was lively and good natured and involved a number of people.

We found the service routinely listened to people’s concerns and experiences about the service. Resident and family meetings were undertaken together with the circulation of a newsletter. An annual questionnaire was also circulated.

People told us they thought the home was well run and managed. They were able speak freely to staff and the manager about any concerns and were confident these matters would be addressed by the home.

Both staff and people told us the manager who was very approachable was responsible for an open and transparent culture at the home. Comments from members of staff included; “The manager is very good, we are all very happy with him.” “The manager is very open. We have an open culture here and the freedom to say what we want.”

The service undertook an extensive range of audits of the service to ensure different aspects of the service were meeting the required standards.

09/04/2014

During a routine inspection

Holly Court Care Home is situated in Salford and provides accommodation and support for people with various types of dementia and confusion. The home does not provided nursing care. Accommodation comprises of 25 single en-suite bedrooms over two floors. At time of our inspection there were 24 people living at the home. There is parking for several cars to the front of the property. The home is close to local amenities and bus routes.

Holly Court had a manager who was registered with the Care Quality Commission (CQC). They had been in post prior to Four Seasons taking over the home in 2011. A registered manager is a person who has registered with the CQC to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider.

We found that information and checks carried out when recruiting new staff were not as robust as they should have been.

We looked at the care records for people who lived at Holly Court. Records were reviewed and kept up to date so that staff were aware of the current and changing needs of people. However we found there was no information to guide staff about the care of one person who had recently moved into the home. This meant this person was at risk of not receiving the care and supported they needed.

In one area of the home we saw two people had not received the appropriate support and had gone into bathrooms and bedrooms of other people.

We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards. Policies and procedures were in place and training had been provided to guide staff in relation to the Mental Capacity Act 2005 and deprivation of liberty safeguards.

People, where possible were involved in most decisions about their care and support. Staff were seen to be kind and respectful to people and had a good understanding of their needs. Staff addressed people by their preferred name and were heard asking people’s permission and explaining to people what they were about to do before carrying out any intervention.

We found that people were offered nutritious and varied meals throughout the day, which met their assessed dietary needs. Staff made appropriate referrals to health care professionals, such as the dietician, where it had been identified that someone was losing weight.

Staff spoken with were positive about their employment and confirmed they were well supported by the manager. Staff told us they had access to on-going training which was relevant to their role. Whilst no recent training had been completed in dementia care. We were told a new programme of training was planned for the service in relation to specialist dementia care.  

Systems were in place to regularly monitor the quality of the service provided to people. The systems were kept under review so that any improvements needed were addressed.

You can see what action we told the provider to take at the back of the full version of the report.

10 September 2013

During a routine inspection

We visited Holly Court on 10 September 2013 and found the home to be warm and welcoming. The staff on duty were friendly and knowledgeable and we observed them delivering care in a pleasant and compassionate manner.

Verbal consent was sought for all interventions and where verbal communication was limited staff endeavoured to take cues from body language and facial expression to ascertain consent. Capacity was explored within care plans and re-visited regularly with regard to specific decision making. Best interests meetings were held where decisions needed to be made on behalf of people who used the service.

We spoke with six people who used the service and three visitors. One person who used the service told us, 'I just have to shout and staff will come to help me'. Another said, 'The nurses know me very well, what I like and don't like.' A visitor told us, 'The staff never ignore us and are always willing to discuss my relative's care'.

We saw that the numbers of staff on duty were sufficient to attend to the needs of the people who used the service. We looked at staff rotas and spoke with staff who told us that staff shortages were always covered by other members of the team.

A number of audits were carried out and the results of these analysed. Action plans and timescales were then produced and any issues addressed in a timely way.

Appropriate policies were in place concerning record keeping, storage and retention. These were adhered to within the home.

22 November 2012

During a routine inspection

We visited Holly Court on 22 November 2012 and saw that the home was warm and clean and people appeared well presented. We observed that care was delivered competently and efficiently and people who used the service treated with respect and courtesy.

There was a choice of meals and snacks and drinks were available throughout the day. Pictorial menus assisted people with confusion to understand the choices available and pictures on the doors of the rooms helped orientate them around the home.

We looked at a sample of six care plans and saw that the information was factual and accurate. Choices and preferences were recorded and there was information about other services involved. Records were up to date and there was evidence of regular reviews with any changes being recorded.

We spoke with two people who used the service. One told us 'They are all very helpful, I am happy here'. The other said 'Staff are all polite'. We spoke with two visitors to the home, who both expressed satisfaction with the service. One said 'We can leave her here and know that she is well looked after'. The other told us 'if anything happens they inform us.'

We saw that appropriate policies and procedures were in place. We saw that safeguarding issues were taken seriously and appropriate steps were taken to investigate and resolve the issues.

We saw evidence of a formal complaints procedure and saw that any issues had been followed up appropriately.