Holly Grange House Care Home

“At the time of our inspection, due to staff vacancies and sickness, staffing levels were being maintained using staff employed through an agency. The provider’s own identified staffing levels were not always reflected in staff rotas and there was variance in the day-to-day allocation of staff. Staff told us they were not always able to respond promptly to people’s requests for support and analysis of call bell response times identified numerous occasions when call bells had been unanswered within the provider’s expected timeframe. Inductions for agency staff were not adequate to ensure they knew what support people needed or how to respond in an emergency.”

“Some aspects of people’s care and support were delivered in line with relevant legislation and good practice. However, staffing arrangements did not consistently ensure people received safe, timely and person-centred care. Good standards of record keeping needed to become embedded in staff practice to ensure effective monitoring of risk management strategies.”

“Medicines were stored, administered, and disposed of safely in line with the provider’s procedures and best practice guidelines. Staff understood their responsibility to keep people safe and told us there was an open approach to learning from mistakes to improve their individual practice.”

“The provider worked in accordance with the legal requirements of the Mental Capacity Act 20025. Records evidenced how staff had tried to involve people in decisions about their care by making information available and accessible to meet their individual needs. Overall, people told us they were able to raise concerns and provide feedback about the service and relatives told us they felt informed and consulted with. However, the provider needed to consider how they captured the experiences and views of those people who were more likely to experience inequality in outcomes to identify where improvements might be needed.”

“Whilst permanent staff were committed and motivated to provide high standards of person-centred care, they told us low numbers of permanent staff and a transition to new policies and procedures meant they could not always achieve this. Leaders acknowledged the challenges faced by the staff team during a period of transition and assured us recruitment and absence management were key priorities in ensuing people received continuity of care.”

“The provider had a detailed service improvement plan (SIP) which was regularly audited by the provider’s quality improvement manager. Where improvements had been made, their effectiveness was monitored to ensure processes were consistently applied and embedded in staff practice. However, some improvements continued to remain a work in progress or had not been addressed effectively during governance processes.”

“Whilst we identified some areas for improvement at this inspection, leaders were responsive to feedback and demonstrated a commitment to improving the quality of care.”

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