Holy Name Community Rehabilitation Centre

Updated 6 June 2023

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

The inspection was completed by 2 inspectors and an Expert by Experience. 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

Holy Name Community Rehabilitation Centre 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. Holy Name Community Rehabilitation Centre is a care home with 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. 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. 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. We used all of this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service and 4 relatives about their experience of the care provided. We spoke with 8 members of staff including the head of services, assistant director, registered manager, deputy manager, nurse and health care assistants. We also spoke to 2 professionals who work with the service.

We reviewed a range of records. This included 6 people's care records and 14 medication administration records. We inspected 4 staff files in relation to their recruitment. A variety of other records relating to the management of the service, including audits and policies and procedures, were also reviewed.

We inspected the environment and spent time observing interactions between people and staff, and infection prevention and control practices.

Updated 6 June 2023

About the service

Holy Name Community Rehabilitation Centre is a care home registered to provide accommodation, personal and nursing care for up to 64 people. This includes people who need short term rehabilitation and reablement support to return home or prevent hospital admission across 3 adapted areas. At the time of our inspection, 56 people were residing at the service.

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

Medicines management was not always in line with best practice guidance; medicine administration records were not always fully completed and guidance for staff not always in place.

Risks associated with people's care had not always been clearly recorded in their care plan or risk assessments with measures which were in place to reduce the risk of harm were not always available to staff.

A system was in place to monitor the quality and safety of the service, however this was not always effective in identifying and addressing issues.

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 did not always support this practice.

People had support from safely recruited staff. Staff received training in safeguarding and understood their role and responsibilities to protect people from abuse. Staff continued to receive guidance and support from management when required.

People and staff spoke positively about the management of the service. There was a positive, caring culture within the service and we observed people were treated with dignity and respect. People were happy with the care they received, they felt safe and well looked after.

Staff had positive links with healthcare professionals which promoted people's wellbeing. Records confirmed the registered manager worked in partnership with stakeholders. We found the registered manager to be open and responsive to feedback. Visiting healthcare professionals told us that the management team and staff worked well with them.

The home was clean and tidy and additional cleaning processes had been implemented to prevent the risk of spread of infection.

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

Rating at last inspection

This service was registered with us on 15 November 2021 under a new provider and this is the first inspection.

The last rating for the service under the previous provider was requires improvement (published on 27 August 2021).

Why we inspected

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

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to medicine management and good governance at this inspection. We have also made recommendations in relation to care planning systems and mental capacity records.

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.