Background to this inspection
Updated
12 February 2019
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This was an unannounced, comprehensive inspection, with visits completed on 26 November and 6 December 2018.
On the first day of inspection, the inspection team consisted of two CQC inspectors. On the second day of inspection, the team consisted of two CQC inspectors and one CQC medicines inspector.
Before the inspection, we received information of concern from external stakeholders. These concerns were reviewed as part of the inspection process. There had also been a recent incident resulting in the theft of medicines including controlled drugs from the service. We liaised with the Police service regarding this incident, and reviewed actions taken by the provider as an outcome during the inspection visits.
During the inspection we spoke with six people who lived at Holmwood. We observed care and support being delivered in communal areas and we also spoke with seven members of staff including the provider, acting manager, care staff, and ancillary staff. We spoke with one visiting healthcare professional. Due to the seriousness of concerns, we made referrals to Norfolk Fire and Rescue Service, the local authority safeguarding team and the local health authority infection prevention control team, after our first inspection visit.
We reviewed nine people’s care plans in detail including their daily contemporaneous notes, weight monitoring, food and fluid charts where applicable. We looked at 13 people’s medicine administration records (MAR) and the medicines management procedures in place. We attended the evening shift handover meeting on the first day of the inspection. We looked at three staff recruitment files as well as training, induction, supervision and appraisal records.
Updated
12 February 2019
This was an unannounced, comprehensive inspection, with visits completed on 26 November and 6 December 2018.
Holmwood is a ‘care home’ for people with mental health conditions and learning disabilities. People in care homes receive accommodation and 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 was registered to have 32 people, there were 24 people living at the service at the time of the inspection. At our last inspection on 16 and 17 March 2017, we rated the service good in all inspection key questions.
Holmwood consists of one large house, with bedrooms, communal bathrooms and toilets across four floors, communal lounges and dining’s areas on the ground floor.
The service did not have a registered manager in post. ‘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.’ The service had not had a registered manager since December 2017. At the time of the current inspection, the deputy manager was acting as manager on a temporary basis, with a replacement manager due to start in post January 2019.
At this inspection on 26 November and 6 December 2018, we found the evidence to support an overall rating of Inadequate.
During this inspection we identified that the service was failing to meet the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of the regulations for safe care and treatment, protection of people’s privacy and dignity, adherence to the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards including sourcing consent, management of people’s nutritional and hydration needs, provision of person-centred care, good governance, meeting the requirements of fit and proper persons and safe staffing. The provider was also in breach of the Care Quality Commission (Registration) Regulations 2009 due to not consistently submitting notifiable incidents to CQC.
During this inspection, we identified serious concerns in relation to staff competency in the safe support of people experiencing mental health conditions. Extremely poor cleanliness of the environment and lack of infection prevention control measures which was impacting on the care people received. There were significant shortfalls in the assessment and mitigation of risks to people using the service.
The service had poor governance processes in place for monitoring standards and quality of care provided. We requested in writing for the provider to make improvements to the service between our first and second inspection visits, we identified a lack of governance and provider oversight in response to our requests. Staff did not complete audits in areas such as infection control and the quality of care records, this was reflected in our findings of the condition of the care environment, the quality of documentation and poor standards of care being provided.
Staff were not implementing training and recognised good practice in the care and support provided to people living at the service. People’s records and staff’s understanding demonstrated a lack of adherence to the Mental Capacity Act (2005). Staff did not recognise or understand the risks and support needs of people diagnosed with mental health conditions.
Low staffing levels significantly impacted on people’s access to meaningful activities and care records lacked detail in relation to people’s hobbies and interests. There was not an up to date, daily activity timetable, and people told us there was not enough to do.
People were not consistently treated with care and compassion, and their privacy and dignity was not always protected. The condition of the care environment was not conducive to the provision of high quality care.
At this inspection we found serious breaches of Regulations 9, 10, 11, 12, 14, 17, 18, 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of the Registration Regulations 2009 . These breaches were assessed by CQC as extreme, as the seriousness of the concerns meant that unless we took the action we believed people would be at risk of harm. The overall rating for this provider is 'Inadequate'.
On 10 December 2018, CQC used its urgent powers to keep people safe, and varied the conditions on the provider's registration to remove this location. This means that it can no longer provide any regulated activities and is closed.
The provider appealed against this decision to the First Tier Tribunal (Care Standards) under section 32 (1) (b) of the Health and Social Care Act 2008. The appeal hearing was held on 28 and 29 January 2019, the decision was made that CQC took appropriate action in light of the seriousness of concern, and the appeal was dismissed by the tribunal judge.
Other stakeholders including the local authority supported people and relatives to find other homes or alternative care arrangements. By 12 December 2018, all people living a the home were safely moved to alternative placements.
Full information about CQC's regulatory response to any concerns found during inspection is added to reports after any representations and appeals have been concluded. You can see the enforcement action we took at the end of this report.