Archived: Holderness House

Updated 25 January 2024

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 Health and Social Care Act 2008.

Inspection team

Two inspectors and an Expert by Experience carried out this inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Holderness House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Holderness House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 11 people who used the service and 1 relative about their experience of the care provided. We also spoke with 11 members of staff including the CEO, the registered manager, deputy manager, cook, activities coordinator, housekeeper, senior care staff and care staff.

We reviewed a range of records. This included 3 people’s care plans, 2 staff recruitment files, staff training records and records associated with the provider's quality monitoring systems.

Updated 25 January 2024

About the service

Holderness House is a residential care home providing accommodation and personal care to up to 33 people. There are five floors altogether, although two were smaller split levels. The service provides support to ladies, some of whom may be living with dementia. At the time of our inspection there were 23 people using the service.

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

Governance systems in place were not always effective at identifying and addressing issues. Audits were carried out and identified areas for improvement, but action plans were not always developed.

Medicines were not always managed in line with best practice, records were not always in place, such as protocols to guide staff when to administer as and when required medicines and special instructions were not always recorded. Medicines were stored safely, and staff had received medicines training. We have made a recommendation about this.

Checks were not always in place to ensure risks were managed, such as window safety checks. Some single pane glass did not have measures in place to manage the risks. The provider started to address this during the inspection. Care plans and risk assessments were in place but required further detail. We have made a recommendation about this.

Staff had been recruited safely and we received positive feedback regarding the staff. The provider used a dependency tool to assess the staffing levels, however information in this did not correspond with people’s care records.

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. However, some records were not sufficiently detailed.

People were happy with the support they received, and we received positive feedback regarding the staff. Staff were supported in their roles and felt there was good teamwork at the service. Communication systems were in place to engage with staff, people and their relatives such as meetings and satisfaction surveys.

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 30 July 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

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 Holderness House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to governance at this inspection and recommendations in relation to medicines and risk management.

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 continue to monitor information we receive about the service, which will help inform when we next inspect.