Archived: Holmfield Court

Updated 5 October 2019

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.

Inspection team

The first day of the inspection was carried out by three inspectors and one Expert by Experience. The second day of the inspection was carried out by one inspector. 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

Holmfield Court 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 did not have a manager registered with the Care Quality Commission. A registered manager 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.

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 also contacted Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

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 eight people who used the service and five relatives about their experience of the care provided. We spoke with eight members of staff including the nominated individual, manager, regional managers, assistant manager, senior care workers, care workers and the chef. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found and received feedback from the provider and local authority.

Updated 5 October 2019

About the service

Holmfield Court is a residential care home providing personal care to 21 people aged 65 and over, most of whom were living with dementia. The service can support up to 25 people.

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

We found multiple concerns at this inspection. The impact of the concerns was that people did not receive safe care and treatment. People’s needs were not fully met, and people were not always treated with dignity and respect.

Following the inspection, the provider has made the decision to close the service. Where a service is rated inadequate overall it would usually be placed into special measures. This is a process which ensures the service is monitored closely. Because the provider has made the decision to close the service on this occasion it will not be placed into special measures.

The provider had failed to protect people from avoidable harm. Risks in the environment had not been managed and staff followed poor infection control processes. In addition, staff and the manager did not recognise or respond appropriately to abuse.

People’s care needs were not routinely reviewed following accidents and visits from healthcare professionals. Therefore, staff were not aware of and did not apply all the control measures in place to reduce risks to people.

Staff were directed to complete tasks, rather than focus on people’s wellbeing and holistic needs. People were not supported to avoid social isolation and engaged in little or no activity. One person told us, “I just accept things. Things are not desperately unhappy or happy.”

The management of the service was ineffective; roles and responsibilities were unclear. The manager told us they were unhappy with the provider’s quality systems; however, we saw no evidence to demonstrate this had been raised or that any action had been taken to address their concerns.

People were not supported to have maximum choice and control of their lives and staff did not treat them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 15 January 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection improvements had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified seven breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 at this inspection. The breaches relate to person-centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse or improper treatment, premises and equipment and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

Following the inspection, the provider has made the decision to close the service.