Holly Park Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm Improvements were required to ensure risks to people’s health, safety and welfare were consistently updated and the environment was maintained safely. Medicines were managed safely. There were enough trained and skilled staff to support people safely and safe recruitment processes were in place. Processes were in place to learn lessons when things went wrong.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a positive approach to learning, with a culture based on openness and willingness to learn. People and relatives told us they knew how to raise concerns and felt confident appropriate action would be taken to address them. Accidents and incidents were recorded and there was evidence action had been taken to mitigate the risks of events happening again. There was a clear process for raising complaints and concerns and action was taken to resolve any issues. Staff knew how to record and report accidents and incidents and how to escalate safety concerns.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, maintaining continuity of care when moving between services. The provider had a pre-assessment process in place which enabled to gather relevant information prior to care being provided. Staff understood their role in supporting people to access appointments and clear records were in place of health appointments.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Overall, we found the provider shared concerns quickly and appropriately.

Safeguarding logs were in place. Staff received training in safeguarding. They understood how to recognise abuse and poor care and report this to their registered manager and other relevant professionals. Overall, we saw safeguarding incidents were safely managed. We found one event which had not been reported and acted upon in a timely way. No further harm had taken place and the registered manager took immediate action to address this and assure us this was an isolated occurrence.

People and relatives told us they felt safe. Comments included, “The staff always make me feel safe and in good hands.”

The provider worked well with people to understand and manage risks. Staff provided care to meet people’s needs that was generally safe, supportive, and enabled people to do the things that mattered to them. However, we found some inconsistencies in people’s care records. The registered manager told us there was ongoing work to improve the quality of people’s care records. For example, where people experienced periods of distressed behaviour, improvements were required to their risk assessments and care plans to ensure staff were aware of the possible triggers and more detailed guidance on how to support people consistently. However, staff knew people well and understood the risks people were exposed to and told us they were kept up to date with changes in people’s needs.

The provider did not always detect and control potential risks in the care environment. The provider had systems in place to ensure the building was maintained safely, including regular checks and audits. The home employed a maintenance worker which meant any issues were dealt with promptly. The home was undergoing a significant refurbishment programme. Whilst this had commenced, people were living in communal areas and using bathrooms which required upgrading. The provider had made improvements to the external areas of the home, to provide a safe and accessible outdoor garden.

The home had a smoking area for people living at the home. Over the course of this assessment, we saw the door was left open which meant there was strong odour of cigarette smoke in the adjacent corridors. We discussed this with the registered manager and they made immediate improvements to resolve this and shared an action plan to further improve the area.

The provider made sure there were enough qualified, skilled, and experienced staff. The provider followed safe processes to ensure staff were recruited and inducted into their role safely. Staff received support, training, and supervision to be able to carry out their roles.

On the second day of the assessment staffing levels had reduced due to slightly lower occupancy. The provider used a recognised dependency tool to assess how many staff were required to support people safely. The provider told us they had considered the layout of the building and the diverse needs of people when making their assessment. We carried out a visit on an evening. Whilst we saw care was provided safely, staff were observing people in the lounge whilst carrying out other duties and were not able to spend quality time with people. We discussed this with the provider and they confirmed observations and regular reviews meant they were assessing staffing levels regularly to ensure they were safe. Staff said they had some concerns about the reduced staffing levels. We received mixed feedback from people and relatives about staffing levels and several comments highlighted more staff were required and there was not always a staff presence in the main communal areas.

The provider did not always assess or manage the risk of infection. Due to shortfalls in the living environment, including damaged décor and furniture, there were challenges in ensuring the home was kept clean. Over the course of the assessment, we noted several areas where there were strong malodours. Staff told us there had been a recent change in the cleaning products provided, which they felt contributed to this.

People and relatives did not raise any concerns about the cleanliness of the home and said staff wore personal protective equipment when this was needed. We observed ongoing cleaning being carried out during the day and staff followed safe practices to minimise the risk of infections spreading.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were stored safely and securely in the home and stock levels checked during the assessment were all correct, including controlled drugs.

People who were prescribed ‘as and when required’ medicines had person-centred protocols in place to ensure staff knew when to administer these appropriately.

Some people self-administered their own inhalers and injections to encourage their independence. Risk assessments were in place to ensure this was managed safely.

Some delivery delays of medicines were acknowledged by the home, but they were in the process of meeting with the GP and pharmacy to improve on this. Staff knew the processes to follow if people went without their medicines for extended periods. Where people were prescribed medicines to support with anxiety, behavioural charts were completed, and staff had a good knowledge of people and how to provide individualized support.