Background to this inspection
Updated
27 August 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by two inspectors on the first day, and one inspection manager and one inspector on the second day.
Service and service type
Holy Name Care Home is a ‘care home’. People in care homes receive accommodation and nursing or 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 service had a manager registered with the CQC. This means they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced on both days.
What we did before the inspection
We reviewed information we received about the service since the last inspection and sought feedback from local authority commissioners and safeguarding teams. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.
During the inspection
We spoke with three people and one person’s relative. We spoke with nine members of staff including the registered manager, general manager, the nominated individual, one nurse, one senior carer, one kitchen assistant, the head chef, maintenance person and the administrator.
We reviewed a range of records including six people’s care records, their medication records, supplementary records including repositioning and food and fluid charts. We reviewed four staff files in relation to recruitment and supervision. A range of records relating to the management of the service, including policies and procedures were also reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We spoke with health care professionals who regularly visited the service. We spoke with a further two people’s relatives by telephone to seek their feedback.
Updated
27 August 2021
About the service
Holy Name Care Home is a care home that can provide personal and nursing care for up to 64 people, some of whom may be living with Dementia. At the time of the inspection, the service was providing care and support to 36 people.
People’s experience of using this service and what we found
People and their relatives told us they felt the service was safe. People felt satisfied with the care they received. However, they were not always consulted for their feedback and suggestions.
The registered manager and provider did not operate effective systems to effectively monitor safety and improve the quality of care provided to people who used the service.
We found people were at increased risk of harm. There were issues relating to people’s safety and the management of medicines. People who were at risk of pressure area damage did not always receive positional changes in line with their individual support needs. Risks to people’s nutrition and hydration needs were not monitored appropriately. Records relating to positional changes and meeting people’s nutrition and hydration needs were not always completed by staff. There was no oversight or analysis of accidents and incidents by the registered manager or provider to improve the safety of people using the service.
The environment, which accommodated people who were living with Dementia, was not designed and decorated in line with best practice guidance. We made a recommendation about considering best practice guidance to inform the environment for people living with Dementia.
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.
For more details, please see the full report which is on the Care Quality Commission’s (CQC) website at www.cqc.org.uk.
Rating at last inspection
The last rating for this service was good (published 22 August 2019).
Why we inspected
We received concerns in relation to the support provided to meet people’s nursing care needs and pressure area care. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Holy Name Care Home on our website at www.cqc.org.uk.
Follow up
We will request an action plan for 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.