15 November 2022
During an inspection looking at part of the service
People’s experience of using this service and what we found
Risks relating to people’s environment had not been fully assessed and placed people at risk of harm. Medicines were not consistently managed safely, and people were at risk of not receiving their prescribed medicines. Infection prevention control measures in place were not effective and required further development to ensure people were protected from the risk of infection. Staff reported and recognised safeguarding incidents however action was not always taken to prevent incidents from reoccurring meaning lessons were not always learnt and there was an increased risk incidents would be repeated.
Governance systems and processes had improved following a recent change in management. However, the provider had not always highlighted areas for improvement. At the time of our inspection the providers senior leadership team were supporting the service to make changes in order to improve the quality and safety of care. Relatives told us they were not consistently involved in planning and reviewing peoples care. The service referred to health and social care professionals when needed. However, feedback relating to communication from professionals was mixed.
Staff were recruited safely and there were enough staff to safely meet people’s assessed needs. Staff told us they felt supported in their roles and felt the recent change in management had implemented positive changes.
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.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 10 January 2018).
Why we inspected
The inspection was prompted in part due to concerns received about the management of incidents and overall management of the service. A decision was made for us to inspect and examine those risks.
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.
We received concerns in relation to the management of incidents and overall management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. 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 good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Holmes House Care Home on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to infection control, medicines management, the environment and governance at this inspection.
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
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.