Holly Lodge Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 1 quality statement in the well-led key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Though the assessment of these areas indicated areas of concern since the last inspection, our rating for the key question remains good. During our assessment of this key question, we found concerns around the governance in the home which resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. The provider did not recognise shortfalls around how staff assessed and managed risk of choking and aspiration which could put people at risk. Audits and checks did not identify referrals to healthcare professionals were not always completed when needed and people’s records were not always reflecting the individual risk of choking, least restrictive options to be used to support them to stay safe and the need to assess their mental capacity for modification of their diet. The provider’s audits did not recognise that not all safeguarding concerns were appropriately identified, reported and investigated. The registered manager did not always notify CQC about events in the home when required. The provider was in breach of regulation around good governance. The provider took action to address those shortfalls following the site visit. Staff were clear about their responsibilities and roles and felt supported by the registered manager and the provider.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders were not always able to explain how they monitored the provider’s choking risk management policy and national guidance in relation to mental capacity were followed by staff. The management team were not always aware when they needed to notify CQC about certain events in the home. Staff told us they were clear about their roles and responsibilities and received good support from the management. Staff members said, “[The registered manager] is very approachable. We have a really good working relationship. Handovers are really clear. We are always discussing different things”, “Me and [the registered manager] always discuss everything so I know what is needed of me to support him”, “[The registered manager] always supports us to implement new things” and “I can raise things and even if I am not in agreement with something, I know I am listened to.”

The provider had governance systems in place. However, these were not always used effectively to recognise shortfalls and address them in a timely way. For example, audits and checks in place did not identify choking risks to people were not always appropriately assessed and referred to speech and language therapy service for support. The management team did not always recognise there was a lack of assessment of people’s capacity and decisions were not always made with due consideration for people’s rights and best interests. Reviews of incidents, accidents and complaints were not always identifying safeguarding concerns appropriately, so not all were reported and investigated in a timely way. Not all events which required CQC to be notified were reported in a timely way. The provider took action to make necessary improvements following the site visit.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.