The inspection took place on 27 June 2017 and was unannounced.

We last completed a comprehensive inspection of Holly Bank in May 2016. We found that the provider was in breach of regulations with regard to safe care and treatment and good governance. The service was rated as ‘requires improvement.’

During this inspection we found that care files we viewed contained care plans for PRN (as required) medication and antibiotics and medication administration records were completed correctly. The service now had robust audit processes which included a number of checks to ensure that people received safe and effective care. The home’s policies and procedures were now regularly reviewed.

Holly Bank Nursing Home is a privately owned care home providing nursing care for 16 older people. Accommodation at the home is made up of ten single rooms and three double rooms. The home is situated in a quiet, residential area of Southport, close to the town centre and all amenities.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Medicines were managed safely in the home.

Risk assessments had been undertaken to support people safely and in accordance with their individual needs.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported.

Safety checks of the environment and equipment were completed regularly.

There were enough staff on duty to provide care and support to people living in the home.

The provider had robust recruitment procedures in place to ensure staff were suitable to work with vulnerable people.

Staff worked in partnership with health and social care professionals to make sure people received the care and support they needed.

Staff were trained to ensure that they had the appropriate skills and knowledge to meet people's needs. They were well supported by the registered manager.

Staff sought the consent of people before providing care and support. The home followed the principles of the Mental Capacity Act (2005) for people who lacked mental capacity to make their own decisions.

People told us they liked the food and were able to choose what they wanted to eat.

People told us the staff had a good understanding of their care needs and their individual needs and preferences were respected by staff.

Care plans provided information to inform staff about people's support needs, routines and preferences.

People told us staff were kind, polite and maintained their privacy and dignity. We observed positive interaction between the staff and people they supported. Staff appeared to be very caring in their manner towards people and their relatives.

A programme of activities were available for people living at the home to participate in.

A process for managing complaints was in place. People we spoke with knew how to raise a concern or make a complaint.

Feedback we received from people, relatives and staff was positive.

People living in the home and relatives told us they were able to share their views and were able to provide feedback about the service.

Systems and processes were in place to assess, monitor and improve the safety and quality of the service.

The registered manager and administration manager met with other home managers in the locality, to share their ideas and information.

The manager was aware of their responsibility to notify the Care Quality Commission (CQC) of any notifiable incidents in the home. The ratings from the last inspection were prominently displayed, as required.

We carried out this inspection on the 23 May 2016. The inspection was unannounced.

Holly Bank Nursing Home is a privately owned care home providing nursing care for 16 older people. Accommodation at the home is made up of ten single rooms and three double rooms. The home is situated in a quiet, residential area of Southport, close to the town centre and all amenities. At the time of the inspection 13 people were living at the home.

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During the course of the inspection we identified breaches of regulations in relation to; the administration of medicines, assessment of risk, quality assurance processes and records.

You can see what action we told the provider to take at the back of the full version of the report.

We observed the administration of medicines and checked relevant records. We saw that the procedures for storing, recording and administration of medicines were not always being carried out safely in accordance with the relevant guidance.

Risk was assessed and reviewed for most people living at the home. However, we saw that some important information relating to risk was missing or inadequate.

Incidents and accidents were accurately recorded. However there was no evidence that the information had been evaluated to identify patterns that might help to reduce risk in the future.

The records that we saw did not clearly demonstrate that the home was operating in accordance with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). There was a mental capacity assessment in each file but they were not decision-specific. There was also an indication that some people living at the home lacked capacity or had fluctuating capacity to make decisions for themselves. It was not clear that people had been fully consulted about decisions or that they had been made appropriately in the person’s best interests.

We have made a recommendation in relation to the MCA and DoLS.

Care plans were basic and focused on clinical needs. They were not person-centred in structure or content and did not reflect the quality of care that we observed.

People and their relatives told us that they were involved in the assessment, planning and review of care. However, the evidence to support this in care records was inconsistent.

Policies and procedures that staff should use to guide their practice and maintain standards had not been reviewed and contained information which was out of date. Other records relating to the management of the home were poorly structured making it difficult to find important information.

The home had systems in place to monitor safety and quality and to drive improvements. However, they had not been effective in identifying issues relating to the administration of medicines, the use of thickeners, capacity assessments and care records.

People told us that they felt safe living at the home. Staff had been trained in adult safeguarding and were able to explain what they would do if they suspected that anyone was being neglected or abused.

Staff had been safely recruited and were deployed in sufficient numbers to provide safe, effective care. The home used a dependency tool to establish the level of care required by each person living at the home and deployed staff accordingly.

Staff were suitably trained and skilled to meet the needs of people living at the home. The staff we spoke with confirmed that they felt equipped for their role. The majority of staff that we spoke with confirmed that they had been given regular supervision and appraisal.

People living at the home and their visitors told us that the food was good

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found -

Is the service safe?

We saw that the recruitment process at Holly Bank Nursing Home was thorough and included all security checks being completed for new staff members before they were allowed to commence work.

The provider had systems in place which helped ensure all staff members learned from any complaints or incidents. This meant that the service continued to improve and people received an improved quality of care and support that met their needs.

Deprivation of Liberty Safeguards (DoLS) become important when a person is judged to lack the capacity to make an informed decision related to their care and treatment. The provider told us no applications for DoLS had been made but knew the procedure to be followed if an application needed to be made.

Is the service effective?

We saw that all people who used the service had signed their care plans which meant they were involved in writing them. This helped ensure their care and support was provided in line with their wishes and preferences. Risk assessments were conducted regularly which meant information related to people`s needs was kept up to date and relevant.

People who used the service had their mobility needs taken into account and were able to move around the nursing home freely and safely.

We were told that people were able to meet in private if they wished to and that visiting times for relatives or friends were flexible.

Is the service caring?

We saw that people`s wishes and preferences had been recorded during their assessment and care and support was provided in line with their identified choices.

We spent time in communal areas and observed staff who were patient and continually encouraged people to be independent when possible. One relative told us, "We made a good choice coming here. It`s a really homely place."

Is the service responsive?

People we spoke with told us they knew how to make a complaint if necessary and were happy any issues would be listened to and responded to by staff members. All accidents and incidents were recorded appropriately and the registered manager told us that all staff members learned from any reported incidents. This was aimed at improving the quality of service being provided.

People who used the service had access to various activities which included meeting their spiritual needs. The registered manager told us if any person asked to attend a Sunday service, they would be supported to do so. A lay-person from a local church also attended the nursing home every Friday.

Is the service well-led?

We saw Holly Bank Nursing Home worked well with other agencies which included GPs and community nurses. This meant people who used the service received care and treatment when they needed it. This showed the provider had a multi-disciplinary approach to providing care.

We saw that the home had a quality assurance system in place. This meant the quality of service being provided was being continually monitored and any shortfalls were addressed. This helped ensure the quality of service continued to improve.

We visited the service and spoke with a number of residents and in some cases, their friends or relatives. Everyone we talked with expressed satisfaction with the service provided at the home and spoke highly of the provider and staff. People’s comments included:

"Matron bought me a new telly! She’s very good to me!’’

"We chose this home because we thought it had a lovely feel and we have not been disappointed. The staff are very nice and they are always very welcoming.’’

"The staff are lovely and pleasant. My mother really likes them all!’’

"I am very happy with the way the home is managed. They look after (name removed) very well.’’

During this inspection, we looked at standards relating to the care and welfare of people who lived at the home. We also looked at how people were safeguarded from abuse. We assessed systems for staff recruitment, training and support and also examined how the provider monitored standards. We found evidence that the provider was compliant in all the areas we inspected and did not identify any concerns.

On the day of our inspection Holly Bank nursing home was occupied by 14 people. There were sufficient staff on duty to meet the needs of the people staying at the home. In our observations, we noted that people were well cared for. We observed staff carrying out daily tasks in a caring and unhurried manner, for example assisting people with their meals and when giving people drinks. When we asked people at the home about how they spent their time, they said that they preferred to spend time in their own room, rather than in a communal area. When we spoke with relatives of people at the home, they commented on how well people were cared for, how they were encouraged to visit at any time, and how staff made them feel welcome. People who were able to talk to us, said that they were happy, comfortable and well looked after in the home.

We visited the service and spoke to people who use the service and their relatives. Generally people we spoke to were satisfied with the care and support given to them whilst living at the home. They told us “They are very good here and look after me well”, “They are very accommodating and everything is addressed”.

We were told that people who use the service were involved in their care choices and preferences as much as possible. Staff respected people’s choices and preferences and they felt they were listened to. Staff respect service user’s privacy and dignity was maintained. We were told by people who use the service and relatives staff always preserved their dignity when attending to personal needs.

Relatives told us they had not seen any information in relation to how to comment or complain. They said they would address any concerns they had to the manager and these were mostly addressed appropriately.