Holly Park Care Home

Updated 1 July 2022

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.

This inspection was to check whether the provider had met the requirements of Warning Notices in relation to Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors, a pharmacist inspector 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

Holly Park 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.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there not a registered manager in post but the manager was in the process of submitting their application for registered manager with the Care Quality Commission.

Notice of inspection

Both days of this inspection were 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 used all this information to plan our inspection.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

We spoke with five people who lived at Holly Park and two relatives about their experience of the care provided. We spoke with five members of staff including the manager, a senior manager, a regional support manager, a care coordinator and the activity coordinator. We reviewed a range of records. This included seven people's care records and multiple medication records. We looked at two staff files in relation to recruitment. 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. We requested some documentation to be sent for us to review remotely.

Updated 1 July 2022

About the service

Holly Park Care Home is a residential care home providing personal care to up to 43 people in one adapted building. The service provides support to older people who may be living with dementia or other mental health conditions. At the time of our inspection there were 15 people using the service.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in West Yorkshire. To understand the experience of social care Providers and people who use social care services, we asked a range of questions in relation to accessing urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

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

The provider had taken sufficient action to address breaches found at the last inspection in relation to managing medicines safely, although some improvements were still needed in relation to protocols for ‘as required’ medicines, management of creams and storage of medicines.

We have recommended that the provider includes the issues we identified in their monthly auditing of medicine management.

People told us they felt safe and risks to their health and safety were assessed and reviewed regularly. Staff knew what to do to make sure people were protected from abuse. There were enough staff available to meet people’s needs. The home was clean, and systems were in place to minimise the spread of infection. Regular checks on the safety of the environment were made.

Since the last inspection the provider had changed the registration of the service which meant they no longer provided nursing care. This meant that a breach recorded at the last inspection relating to supporting nursing staff was no longer relevant. Staff had received the training they needed to support people safely. Staff worked with healthcare professionals such as GP’s and district nurses to make sure people’s health and social care needs were met.

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 supported this practice.

People’s needs and choices were assessed and reviewed regularly. People were supported to make choices for themselves but they, or where appropriate, their families were not always involved in developing their care plans.

Care plans were person centred, promoted people’s rights to choose, promoted independence. and contained good detail of people’s choices. However, some care plans did not always contain all the information staff might need to make sure people’s needs were fully met.

People had 'This is me’ documents which helped staff get to know and understand the person.

People’s wishes for end of life care had not been explored.

Care plans were in place to support people with their communication needs and staff understood how people’s behaviours might communicate how they may be feeling.

People were supported to engage in activities they enjoyed, and links were being forged to support people to become part of local village life.

The provider had made some improvements in monitoring the quality and safety of the service, but some improvements were still needed. The provider was asking people, staff and relatives for their opinions about the service. Complaints made to the service were managed and responded to well.

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 inadequate (published 20 August 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since August 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 8 June 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve Safe care and treatment, Person-centred care, Staffing and Good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective, Responsive and Well-led which contain those requirements.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the Safe, Effective, Responsive and Well Led sections of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

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 are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.