The Care Quality Commission (CQC) has taken action to protect people at Hollies Nursing and Residential Home Limited after rating it inadequate and placing it in special measures following an inspection in October.
CQC undertook an unannounced focused inspection to look at whether it is safe and well-led, following concerns in relation to staffing and the management of the home, medicines, and safeguarding issues.
The inspection was also prompted by the death of someone living at the home. Due to this incident, inspectors also looked at how the home manages choking.
The service, which was previously rated as good, is now inadequate overall and has been placed into special measures to focus the Hollies leadership team on the areas where rapid improvements are needed. CQC has also rated the service as inadequate for being safe and well-led.
At the time of inspection, there was a formal suspension on admissions to the home until commissioners were assured improvements had been made. The provider had drawn up an action plan, for improvements designed to ensure the safe running of the service.
Hollies Nursing and Residential Home Ltd provides personal care and nursing care for up to 31 people, some of whom are living with dementia. When CQC inspected there were 29 people living in the home.
Hayley Moore, CQC’s head of adult social care inspection, said:
“When we inspected Hollies Nursing and Residential Home Limited, we were very concerned people were exposed to the risk of harm due to poor processes and systems. This is why we have placed them into special measures and downgraded their rating from good to inadequate.
“Our inspectors saw risks around choking, weight loss and dehydration. Someone at risk of weight loss wasn’t being weighed regularly. Also, falls weren’t always being identified, meaning there weren’t any plans in place to reduce the risk of them happening.
“We had other concerns around people’s safety. A high number of safeguarding allegations, including unexplained bruising on one resident, had been made by external organisations but had been missed by the home and not referred to the safeguarding team for further investigation. The interim manager immediately actioned this during the inspection.
“It was also very worrying staff felt unable to speak up about these issues, where they could have provided valuable insight for management to learn from. They also told us there was a culture of bullying and leaders weren’t addressing this or promoting a positive culture. This must be urgently addressed.
“However, within a short space of time the new interim manager had started to build a supportive culture for staff, and was providing clear and effective leadership.
“We will monitor the home closely and will not hesitate to take further action if we feel people are not safe and at risk of harm.”
Inspectors found the following:
- Staffing levels weren’t always sufficient to meet people’s needs. Many staff had left and so they were using a high number of agency staff which meant vulnerable people were not receiving care from familiar faces. Staff didn’t always have the right training or skills to care for people safely.
- The provider's quality assurance systems and audits were ineffective. There had been a lack of oversight by the provider which had resulted in a number of shortfalls that placed people at risk of not receiving proper and safe care.
- Individual's risks including the risk of falls, choking and the deterioration of people’s conditions were not routinely identified. This meant measures were not always in place to reduce these risks.
- There were significant gaps in the reporting and management of accidents and incidents. The provider had failed to notify local commissioners about incidents that had occurred. Medicines were not always managed safely. Systems and processes to safeguard people from the risk of abuse were poorly developed.
- Policies didn’t enable staff to support people to have maximum choice and control of their lives. We found blanket restrictions in place, and decisions weren’t always made in people’s best interests.
However:
- People were protected from the risks associated with the spread of infection, including from COVID-19.
- The provider had recently brought in an external interim manager who had experience of supporting homes to improve. They had prioritised a number of areas for improvement, including reviewing people's needs to ensure they received safe care and treatment.
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