Hollymount Residential and Dementia Care Centre

Updated 20 January 2023

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.

Inspection team

The inspection was carried out by two inspectors, a medicines inspector and an Expert by Experience on the first day, and one inspector on the second day. 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

Hollymount Residential and Dementia Care Centre is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Hollymount Residential and Dementia Care Centre is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was 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 who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 7 people who used the service and 3 relatives. We spoke to 10 staff members. These included, 1 activities co-ordinator, 1 maintenance officer, 5 carers, the nominated individual, home manager and the registered manager. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed 9 medicine administration records and looked at medicines related documentation. We observed medicines administration and checked medicines storage. We looked at 5 people’s care records and associated documents. We also looked at 3 staff files, training and supervision records, as well as records relating to the operation and management of the service. We undertook a tour of the building and completed observations of support provided in the communal areas.

Updated 20 January 2023

About the service

Hollymount Residential and Dementia Care Centre is a residential care home providing personal care to up to 38 people. The service provided support to older people, people living with dementia, people requiring support with their mental health and/ or physical health needs. The service consists of a two-storey building with an extended annex to the rear of the property. At the time of our inspection there were 34 people using the service.

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

We found medicines were not managed safely across the home though some actions were taken following the inspection to improve. Care staff expressed mixed views around staffing levels. We have made a recommendation about the use of staffing tools.

People felt safe in the service. Systems were in place to safeguard people. Environmental checks were being completed. The environment was in need of some repair and work was ongoing to renovate. Infection prevention and control measures were in place although not always robust. Immediate action to address this was undertaken by the provider.

Preadmission assessments were completed, and care plans were reviewed. Staff received training and regular supervisions. People’s diet and nutritional needs were met, and they told us they enjoyed the meals. The provider worked in partnership with other agencies to maintain people’s health and wellbeing.

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 religious and cultural needs were considered. People were treated with dignity and respect and had choices over their care. People were involved in meetings at the service and both people and relatives felt the staff were caring.

People were supported to have person centred care. End of life care was considered and planned for. Activities were offered at the service and processes and systems were in place to respond to complaints.

Systems and processes are not always effective to oversee and manage the service. We have made a recommendation about the provider’s audit systems. Mixed views were given by staff around the approachability of management. Duty of candour was understood by the registered manager and partnership working was seen. Views around the service was being sought from people, relatives and staff.

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 31 March 2022) and looked at the safe, effective and well led domains only. The last comprehensive inspection that looked at all five domains was 15 April 2020.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

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 Hollymount Residential and Dementia Care Centre on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe management of medicines at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.