A care service in Berkshire has been rated inadequate for a second time by the Care Quality Commission (CQC), and will remain in special measures, following an inspection carried out in July.
Holly Grange Residential Home based in Thatcham, Berkshire provides accommodation and personal care for up to 19 people. It provides support to older people, including people who live with dementia. At the time of this inspection there were nine people using the service.
It was previously rated inadequate and placed in special measures following an inspection in November last year. This latest inspection was carried out to assess whether improvements had been made, but the service was still found to be inadequate. There have been repeated breaches in relation to safe care and treatment, gaining consent to care, recruitment procedures and good governance.
As well as being rated inadequate overall following the latest inspection, the service remains rated inadequate in safe and well-led. Effective, caring and responsive remain rated as requires improvement.
CQC has taken further enforcement action, which will be reported on when legally able to do so. But in the meantime, Holly Grange Residential Home remains in special measures, it continues to be closely monitored by CQC. If significant improvements are not made, enforcement action will be taken which could lead to closure of the service.
Serena Coleman, CQC deputy director of operations in the South, said:
“When we inspected Holly Grange Residential Home, we were disappointed to find the provider hadn’t addressed our concerns raised in the previous inspection in November.
“We were concerned that people weren’t living in a service where they had maximum choice and control of their lives with staff providing support in the least restrictive way possible and in their best interests.
“People were at risk of inappropriate restraint because they didn’t always have information in their care records to confirm if physical interventions had been approved when they were needed. Staff hadn’t been trained to complete physical interventions or restraint and this put people at risk.
“People weren’t always receiving the right care because care plans failed to record accurate and consistent information about people. For example, when there were strategies in place to monitor people’s fluids to help support those people at risk of constipation, we found these records were not completed.
“Leaders here haven’t taken our previous feedback and used it to make the rapid improvements we told them we expected to see.
"People deserve a much higher standard of care than what’s being provided by Holly Grange Residential Home. The service will remain in special measures, and we will be keeping it under close review. If we don’t see significant improvement, we won’t hesitate to take further action, even if this results in the closure of the service."
Inspectors found:
- There were seven occasions when staff failed to ensure the equipment was safe to use. For example, brakes not being applied on wheelchairs or stand aids and footplates not being used on wheelchairs, putting people at risk of falls and injury
- Safe food practices were still not consistently followed
- People were at risk of being trapped in bed rails. During the inspection one person did not have their protective rail bumper in place. Staff had been supporting the person but had failed to realise the bumper was not in place
- Medicines weren’t managed safely
- The building was not well-maintained, with ineffective infection prevention and control procedures to keep people safe
- Communication needed to become more effective with relatives and people using the service to keep them informed and to respond to feedback and concerns.