Archived: Holmers House

Holmers House is a residential care home providing accommodation and personal care to people predominantly aged 65 and over, including those living with dementia. The service comprises of three separate wings; Willow, Mimosa and Juniper. Each of which has separate adapted facilities. The service can support up to 48 people and there were 34 people living at the home at the time of the inspection.

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

People were safe at the home. Staff ensured appropriate measures were in place to manage any risks identified to people. Staff adhered to good infection control practices. The registered manager aimed to ensure adequate staffing levels to keep people safe, however, we received mixed feedback from people about staffing.

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 were supported to eat well, and they had help with accessing healthcare services. Staff received ongoing training that was relevant to their roles.

People told us staff were kind. Staff treated people with dignity and respect. People were supported to be independent and encouraged to take positive risks. People’s confidentiality was respected. Staff were committed to valuing people’s and each other’s diverse and cultural needs.

People received support that met their care needs although it was at times led by tasks rather than led by people’s individual preferences. The provision of activities needed improving as the activities were not always meaningful and did not reflected that people’s cultural and social needs were explored. People’s care plans reflected people's assessed care needs and support they had.

There was a new registered manager in post who worked to improve the culture at the home. Staff were encouraged to attend team meetings and be involved in the running of the service. The team worked well with partners and external professionals who were complimentary about the improvements made.

Rating at last inspection and update:

The last rating for this service was requires improvement (published 7 March 2019) and there were four breaches of regulation found. We issued a Warning Notice around two regulations; around the records, quality assurance and keeping people safe from harm including management of medicines. The provider was required to achieve compliance with these two regulations by 4 April 2019. We also issued a requirement notice around regulations around safeguarding of people and person-centred care. The provider completed an action plan to show what action the planned to take to address these concerns.

At this inspection we found improvements had been made; people were safe, protected from harm and had their medicines as prescribed. People were supported to have their needs met and the team worked hard to improve the culture at the home.

We identified one breach of the regulations. The provider did not have oversight to ensure improvements were implemented well within the service.

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

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will request an action plan from the provider to understand what they will do to improve. As this is repeated requires improvement rating we will also meet with the provider following this report being published. This is to discuss how they will make changes to ensure they improve their rating to at least Good. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

This inspection took place on 18 and 19 December 2018 and was unannounced on the first day. We previously inspected the service in April 2018. The service was not meeting all of the requirements of the regulations at that time and was rated ‘requires improvement’.

Following the last inspection, we asked the provider to complete an action plan to show how and when they would improve the key questions safe, effective, caring, responsive and well led to at least good.

Holmers House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Holmers House accommodates 48 people in one adapted building. The service accommodates 16 people across three separate units, each of which have separate adapted facilities. All of the units specialise in providing care to people living with dementia. At the time of our inspection there were 33 people using the service.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At out last comprehensive inspection on 10 and 11 April 2018 we identified a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) 2014. The service failed to provide person centred care that met people’s needs and reflected their preferences. This inspection found a continued breach of Regulation 9 and a breach of Regulations 12, 13 and 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

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

We received mixed views from people about feeling safe living at Holmers House. Several people confirmed that they were still susceptible to falls, however, were able to confirm that their environment was safer for them than where they lived previously. Some people told us they had been hit by another person at Holmers House.

We observed medicine administration and checked the stock levels of prescribed medicines. We found some people had been without their medicines due to insufficient stock. We saw some people were on fluid charts due to their assessed needs. The system used by the service to record people’s fluid intake had been incorrectly calculated. This meant people were at risk of dehydration and we made the registered manager aware of this during our inspection.

The provider did not have systems in place to ensure the service offered quality care and support. Some people were at risk of harm from other people living at Holmers House. Risks to people were not managed safely. Providers are required by law to notify us of significant events that occur in services. We found safeguarding alerts had been made by the service and managed appropriately.

People told us there was a choice of meals and said there was plenty to eat. Staff were aware of the support people required during meal times.

We found four breaches of the Regulations. Full information about our regulatory response to the more serious concerns found during inspections, is added to reports after any representations and appeals have been concluded. We found one domain being rated inadequate, we will re-inspect within six months and if this or any other domain is then rated inadequate, the service will go into special measures.

Following the last inspection, we met with the provider and asked them to complete an action plan to show what they would do and by when to improve the key questions safe, effective, caring responsive and well led to at least good. During this inspection we found some improvements had been made. However, we found a continued breach of regulation in relation to person centred care.

Holmers House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Holmers House accommodates 48 people in one adapted building. The service accommodates 16 people across three separate units, each of which have separate adapted facilities. All of the units specialise in providing care to people living with dementia. At the time of our inspection there were 33 people using the service.

The service requires a registered manager to manage the service. At the time of our inspection a registered manager was not in post. The service was being managed by a registered manager from another location.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People we spoke with told us they felt safe living at Holmers House. One person told us, “I am grateful for a place like this, it is safe, no-one interferes and they leave you alone.”

Staff had received training in the administration of medicines and were assessed as competent to carry out this role. However, we found medicines were not always managed appropriately and some people had not always received their medicines due to insufficient stock.

Records relating to recording of food and fluids were not always completed accurately. People on restricted fluids did not have their daily intake recorded accurately for staff to see how much they had received.

People were not always supported to have maximum choice and control of their lives; policies and systems did not support this practice.

Staffing levels were adequate to ensure people received care in a timely manner. Staff had received training in topics such as moving and handling, mental capacity and fire safety. Regular supervisions and reviews of performance had not been carried out in the past. However, there was now a system in place to ensure that staff received adequate support. Staff told us they felt supported by the management of the service.

Staff had received training in safeguarding and told us they knew what to do if they suspected someone was being inappropriately treated. We spoke with a member of staff who told us they had reported poor care practice in relation to medicine administration.

The provider had robust recruitment files in place to ensure only suitable staff were appointed. Files we viewed had proof that Disclosure and Barring Service checks (DBS) had been completed.

We found people’s care was task-focussed and not person-centred.

One relative we spoke with told us, “Staff congregate in corners with no awareness of what is going on.” The delivery of high quality care was not assured by the culture of the service.

People told us the food was good and they were given an option. People with swallowing difficulties had pureed or soft food.

People had no social stimulation and were asleep in lounges for most of the day. One relative told us they took their relative to a day centre to give them some form of social interaction. The relative told us, “Dad comes to life when he is there.” There was no indication from any information and notices in the Home and from what people told us that people from the community visited Holmers House at all apart from a monthly church service.

Information about advocates was not present in the service. We did not see a comments or suggestion box for people, visitors and relatives to make any comments about the service. Systems were in place for managing complaints but information on how to raise a complaint was not available for people living with dementia.

People had access to other professionals such as community mental health nurses and the GP. These services were accessed when required.

The service employed domestic staff who were responsible for the cleaning of the home. We saw the home was clean and free from odour when we visited.

We found breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

The inspection of Holmers House commenced on 16 August 2017 and was unannounced. This was a scheduled inspection that followed up breaches from the previous inspection when the service was rated requires improvement. We discovered on arrival at the service that the registered manager was not currently in post and was not working at the service. We were told that this was due to the provider identifying lack of progress in working towards the action plan to address requirements from the previous inspection. The deputy manager was managing the service in their absence. We were aware that a compliance company were working with the provider to ensure improvements were made. We were told that a manager from this company would be in place at the service the week following our inspection visit.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The last inspection carried out on 31 May 2016 identified breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 and found a number of improvements were required at the service. We asked the provider to take action to make improvements in relation to the management of medicines, meeting nutritional and hydration needs, ensuring the premises were clean and carrying out care and treatment in conjunction with people’s needs. The provider sent us an action plan setting out how they would take action to address the breaches in regulations.

Following this inspection, we do not consider that the service has attained compliance with regards to the previous breaches of regulations.

People using the service were not always treated with dignity and respect. We observed undignified care practices during our inspection. People’s rights and choices had not always been respected.

Staffing levels were not assessed using a dependency assessment tool. Relatives told us and our observations showed that care and support was not always provided in a timely manner. We received different views from people and relatives we spoke with about the staffing levels. Some told us it was satisfactory whilst others said sometimes there was only one member of staff available. We observed staff did not identify themselves by wearing their name badges. Comments from relatives were, “none of your staff wear name tags which can cause problems identifying people.”

The quality assurance systems in place were not effective. We found continued issues as part of our inspection relating to accurate completion of records. Quality assurance systems had identified some of the issues; however it was not always clear that they had been acted upon.

A visiting professional told us simple instructions were not followed by staff. They also commented on the lack of leadership and that there did not appear to be anyone managing the units.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible. Policies and systems were in place regarding the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We observed practice on one unit which did not afford people the right to make decisions about their care.

The service had documents which were used to record food and fluid intake for people who may be at risk of dehydration and malnutrition. However, examples we reviewed were not always completed effectively. For example, some charts we viewed showed on some days people only had a total of 600ml of fluids. In addition staff had documented in one person’s record, “urine was dark and cloudy”, but had not referred this to the GP or taken any other action.

Staff had received training in topics such as fire safety, mental capacity and moving and handling. Staff had not received regular reviews of their performance and supervisions were not carried out on a regular basis.

People were not always safeguarded from abuse at Holmers House. Staff had received training in safeguarding and told us they knew what to do if they suspected someone was being inappropriately treated. However, this did not correspond with our inspection findings. We were made aware of inappropriate treatment of a person but staff failed to report this practice. We have made the deputy manager aware of this and investigations have commenced.

Staff had received training in the administration of medicines and were assessed as competent to carry out this role. However, we found medicines were not managed appropriately and we found some people had not received their medicines due to insufficient stock.

Health and safety checks had not identified that fire extinguishers were not in the correct place to ensure in the event of a fire staff would be able to easily access them. For example, we saw all of the fire extinguishers in one of the units were taken off the wall and placed in the corridor. We discussed this with the deputy manager who told us every time they put the extinguishers back on the wall a person who resides on the unit took them off the wall. This practice had been going on for a year. We asked the regional manager to rectify this situation with immediate effect. They said they will look into alternative ways of ensuring the person cannot remove the extinguishers from the walls. We spoke with the local fire brigade inspector following our visit who said they will visit the home to check the risks to people.

We noted that window restrictor checks had not been completed weekly as stated in the health and safety file. This had been alerted to staff on the electronic care plan system but remained incomplete. We raised this with the deputy manager. They told us they would address this with immediate effect.

Records relating to the safe use of a repose mattress had not been completed. Weekly mattress checks were incomplete. We saw several gaps in the completion of this task; from 21 June 2017 to 12 July 2017 nothing had been completed to evidence the mattress was in correct working order.

The provider failed to act on information found during the audit process. We saw some actions of audits had not been completed or signed off as completed by the relevant person.

The provider did not have robust recruitment procedures in place prior to staff commencing their employment. The files we viewed did not have proof that the member of staff had a Disclosure and Barring Service check completed (DBS). We asked for further information following our inspection.

We found people’s care was task-focused and not person-centred. We observed staff took people into the lounges where they spent the day asleep in front of television sets without staff interaction. Some people we saw were walking up and down corridors for most of the day without any interaction or distraction from staff. One family member told us they had told staff they did not want their relative pacing up and down the corridor as it tired them out. The relative told us, “nothing changed.”

People’s or their family member’s involvement in the review of care plans was not always clearly recorded. However, people we spoke with said they were happy with the service they received and that they felt safe. The service had policies and procedures in place for reporting any concerns they had about the safety of people they supported.

The majority of people and their family members told us that they knew how to raise a complaint and felt confident that the staff and management would act upon them. The service had a complaints policy and procedure in place. However, records showed that complaints had not been dealt with appropriately.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Full information

The previous inspection was carried out on 10 June 2014 and was fully compliant at that time.

Holmers House is a purpose built residential home divided into three care units each with 16 places. Two units are on the ground floor whilst the other unit is on the first floor. At the time of our inspection there were 45 people living in the home.

There was a registered manager in place at the time of our visit. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We were not able to speak to many people at Holmers House but these were some of the comments we received. One person told us, they liked living in the home and said, “It’s ok as long as I have my music on”. Another person told us, “It’s alright but I would rather be at home”. During both days of our inspection we observed people appeared happy and content living in the home.

Staff reported lack of support and supervision. One member of staff told us they had supervision sometime last year but could not remember when. Another member of staff told us, “We are short- staffed and it is difficult trying to keep my eye on what the agency staff are doing.”

The risk assessment process to identify risks to people and how they were to be eliminated or managed were not always being carried out or recorded. This meant people were not always being protected from identifiable risks to their health and safety. People’s care plans did not always reflect the care that was carried out.

Staff had received training in topics such as fire safety, manual handling and mental capacity.

The home had agency staff who work in the home due to difficulty in recruiting permanent staff. However, the home tried to ensure the same staff were requested from the agency.

Staff had received training in the administration of medicines. Medicines were administered safely and in a timely way. However, medicines were not stored safely within the correct temperature as advised by the manufacturer.

Activities were planned in accordance with the people who were able to participate. We saw people participating in activities on both days of our visit.

We observed staff to be rushed and task-focused and had little time to positively interact with people.

Internal audits had not identified areas for improvement. We made a recommendation in relation to audits.

The service did not have a cleaning schedule to identify areas that had been cleaned or were in need of cleaning. The kitchen had expired food stored in the fridge and we could not see any evidence that the kitchen had been cleaned.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary describes what people who used the service and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

We found people were protected against the risk of harm in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Where people were assessed as lacking capacity, appropriate procedures were followed to ensure arrangements were in people's best interests and in line with legal guidelines. The provider was aware of DoLS changes and had contacted the local authority for guidance.

We saw incidents involving people with challenging behaviour which had been identified as a risk. We saw appropriate risk assessments where in place and professional input was sought to ensure people were safe. Where incidents happened, these were reported to the relevant authority and care plans and risk assessments where updated accordingly. We found safeguarding posters for people who used the service, staff and visitors were readily available throughout the service containing the local authorities contact details and how to raise a concern.

Is the service effective?

We saw regular audits where undertaken to ensure the quality of service provision. Where it was assessed that a person had refused to take their medication, appropriate mental capacity assessments were undertaken and professionals where involved to find the least restrictive manner to administer medication without unnecessarily depriving the person of their liberty. We found the provider had effective recruitment procedures in place when recruiting new members of staff.

Is the service caring?

We saw examples of good person centred practice during our visit. People where spoken to in a kind and friendly manner. One person told us 'The staff are all lovely.' We saw people were supported to go outside at their request as it was a warm day. We observed one person dancing with a member of staff which they appeared to enjoy. Where people requested items from staff, these where met promptly, for example, custard instead of ice cream and salt with their lunch. We saw people participated in activities at their discretion. One person told us 'I played bingo earlier and I won!'

Is the service responsive?

We saw staff were visible and available during our observations on all units. Where people made requests these were met promptly. On our arrival we saw people requesting breakfast and saw their choices were met. We saw staff reacted promptly when a person had an accident in the communal area. Care plans were updated regularly with any changes to people's care.

Is the service well-led?

Regular audits where undertaken within the service and residents and staff meetings where held which fed back into the service. We saw complaints were fed back into the service and accidents and incidents were analysed to identify trends or patterns. Staff told us they felt management where approachable and supportive however they would like them to be more visible.

People told us they were well cared for by staff. We observed positive communication between people and staff. One person said: 'The staff are very nice.' Another person told us 'We get a lot of help.' A staff member told us that 'The care for residents is awesome.'

The home was spacious and clean with individual en suite rooms and pleasant gardens. One person told us 'I'm very comfortable, very happy here.'