This inspection took place on 7 and 12 September 2017. The first day of our inspection visit was unannounced. Hollybank House was last inspected in May 2016 and was rated as Requires Improvement. Following our inspection the provider sent us a plan to show what action they were taking to rectify the breach. On this inspection, we found that improvements had been made, and the service now met all requirements of the relevant regulation.

Hollybank House provides personal and nursing care for up to 45 people. At the time of our inspection, there were 36 people living there.

The service had a registered manager at the time of our inspection visit. 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.

The provider was not consistently meeting the legal requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DOLS). The provider could not demonstrate the relatives had the correct legal authority to consent on behalf of people who lacked capacity to consent to their care. People and their relatives confirmed that staff sought permission before offering personal care. Appropriate arrangements were in place to assess whether people were able to consent to their care.

Systems were in place to monitor the quality of the service provided and ensure people received safe and effective care. However, the systems had not identified several issues in relation to checks on pressure-relieving mattresses, record keeping for topical medicines, and record keeping for people’s fluid intake. The registered manager took immediate action to address this. There was an open and inclusive culture within the service, and staff had clear guidance on the standards of care expected of them.

People felt safe, and were protected from the risk of abuse and avoidable harm. People’s care needs were assessed and recorded, and risks associated with their health needs identified. Risk assessments and care plans set out what staff should do to reduce the risk of avoidable harm. Accidents and incidents were monitored and reviewed, and action taken to reduce the risk of harm occurring.

People were happy with staff who provided their personal care. They were cared for by sufficient numbers of staff who were suitably skilled, experienced and knowledgeable about people’s needs. Staff had guidance about how to meet people’s individual needs. Care plans were regularly reviewed and updated to meet people’s changing needs and preferences.

The provider ensured potential staff were suitable to work with people needing care. Staff received supervision and had training in a range of skills the provider felt necessary to meet the needs of people living at the service.

People had medicines available when they needed them and in accordance with prescribing instructions. Staff worked in cooperation with health and social care professionals to ensure that people received appropriate healthcare and treatment in a timely manner.

People felt cared for by staff who treated them with dignity, respect, and kindness. The support people received was tailored to meet their individual needs, but records did not demonstrate how people were involved in reviewing their care. People, relatives and staff felt able to raise concerns or suggestions in relation to the quality of care. The provider had a complaints procedure to ensure that issues with quality of care were addressed. The provider also sought people and relatives’ views in order to take action to improve the quality of the service.

This unannounced inspection took place on 24 and 25 May 2016. The service was last inspected on 11 April 2014 when all standards were met and no concerns identified.

Hollybank House is registered to provide accommodation for up to 45 older people. At the time of our inspection, 37 people were living there. The service is also registered to care for people who need nursing or personal care.

The service had a registered manager. 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.

People’s dietary needs were not consistently understood. Staff were not always aware of people’s specific dietary requirements. Care records did not always contain specific guidance for staff on how to meet people’s nutritional needs. Where risks had been identified, these were appropriately monitored and referrals made to relevant professionals where necessary.

Where people lacked capacity to make certain decisions, the provider did not always follow the principles of the MCA to ensure best interest decisions were made lawfully. People were supported to make their own decisions about their care where they had capacity to do so.

People’s needs were assessed but care plans did not consistently provide staff with guidance on how to meet people’s individual needs. Risk assessments and care plans were regularly reviewed and updated to reflect people’s changing needs.

Staff training was not consistently undertaken where the provider had identified the need for refresher training. Staff received one-to-one support from their manager, and formal personal development plans, such as annual appraisals, were in place.

People had varying levels of support to maintain hobbies and interests. People who were able to engage in group activities took part in the opportunities offered at the service. Relatives felt that people who were less able were less likely to have activities offered that were meaningful to them.

The provider had systems in place to monitor and review the quality of care at the service. However, these did not always identify risks or areas where action needed to be taken.

Medicines were managed safely and in accordance with current regulations and guidance. Staff received appropriate training to help ensure safe practice. There were systems in place to ensure that medicines were stored, administered, recorded and audited regularly.

Safe recruitment procedures were followed and the provider made appropriate pre-employment checks to ensure staff were safe to work in the care sector. There were policies and procedures in place to keep people safe from the risk of abuse. Staff understood and felt confident to raise concerns about people’s care.

People received care and support from staff who were kind, caring and confident to meet their individual needs. People were supported to access health and social care services when required.

There was a formal complaints process in place. People and their relatives were encouraged to express their views about their care, and the provider was responsive to these.

People were not always kept safe from the risk of avoidable harm. Risk assessments did not consistently identify the level of risk, or identify what actions staff should take. People were able to access areas of the home that presented a risk to their health and safety. This was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

On this routine inspection we spoke with seven people living at Hollybank House, two visiting relatives, two members of staff and the registered manager.

We considered all the evidence we had gathered under the outcomes we inspected.

This is a summary of what we found.

Is the service safe?

People told us that they felt safe and were reassured by staff if they were concerned about anything.

Robust safeguarding procedures were in place. Staff understood their role in relation to safeguarding and were able to tell us how they would report any concerns regardless of how minor they may seem. Staff understood how to safeguard people from potential harm.

There was a system for monitoring quality and safety to ensure that people received safe and appropriate care and treatment.

The medication system in place was safe. The manager intended to review the system for recording the administration of creams to ensure people had the correct treatment prescribed for them.

CQC monitors the operation of the Deprivation of Liberty Safeguards 2009 which apply to care homes. While no applications have needed to be submitted, correct policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

People’s needs were assessed prior to using the service. Care plans were reviewed regularly to ensure their needs were being met.

People’s health and care needs were assessed with them. They were involved in writing and agreeing their plans. Where people did not have the capacity to consent to their care, relatives were involved to ensure their best interests were followed.

An independent advocacy service was available if people needed independent support or advice about their care.

Where people were subject to mental capacity assessments decisions were made in the best interests of the person. However, there was not always recorded evidence of all the people involved in the decision making process.

Is the service caring?

People told us they made choices about their lives. One person told us, “Staff ask my views about how I wish to be supported.”

People told us that their rights and dignity were respected at all times.

A relative told us, Staff handle (my relative) well. I am surprised they also support and reassure me. I feel able to rebuild my own life.”

We spoke with seven people and asked their opinions about staff and the support they received. Feedback was positive. One person said, “I have no complaints about staff, they will do anything for us.”

Each person had a document that was completed with them called ‘This is me’. This recorded peoples preferences, interests, aspirations and diverse needs. This meant that care and support was provided in accordance with people’s choices.

Is the service responsive?

People were aware how to make a complaint. There were clear procedures stating how complaints would be handled. No complaints had been received since our last inspection.

When people’s health care needs changed, external health care professionals were contacted. Their advice was recorded and actioned.

Minutes of staff meetings, resident and carers meetings were actioned to improve the quality of service.

Is the service well-led?

Regular staff meetings were held. Staff felt able to raise any concerns in staff meetings, supervision or on demand day-to-day.

Quality assurance systems were in place. We saw that shortfalls identified had been addressed

People using the service were encouraged to raise any matters of concern. Staff said they felt listened to and that suggestions made were always considered.

Staff were clear about their roles and responsibilities. They felt supported with training and supervision and by senior staff and the manager. Staff felt confident in their ability to meet people’s needs. This ensured that people received a good quality service at all times.

The purpose of this visit was to check if the provider had taken actions to address the

findings of our visit on 3 April 2013. The provider had sent us an action plan showing that they had addressed our findings in April. We referred to this action plan, and the report from our previous visit, at this visit.

We spoke with two relatives of people who use the service and they were positive about the quality of staff recruited to work at Hollybank House. One relative said, “I can’t fault the staff.” We also asked two members of care staff about their experiences at appointment. They both described safe recruitment practices by the service.

We read the files of two recently appointed members of staff and found that the service’s staff recruitment procedures met legal requirements.

On the day of this inspection there were 37 people using this service. We spoke with one of these people, and with two relatives, about how people were supported there. We also spoke with two members of staff. We read the care plans of two people to find out more information on the quality of service provided at Hollybank House.

The people we spoke with said that staff talked things over with them before carrying out their care and asked for their consent before decisions regarding their treatment. Staff respected people’s personal preferences and people thought that their needs were being met. One person told us, “[There’s] not much that you ask for and don’t get…nothing, in fact.” Care plans were clearly centred on people’s particular, individual needs.

People told us that the premises were kept clean. We found that there were effective systems in place to address the risk and spread of infection.

People thought that staff were recruited safely. However, we found that the service’s recruitment and selection processes were not fully meeting legal requirements.

We found that most records were being kept securely and care plans were easily accessible to staff. One relative told us, “I’ve not needed to see records… all my questions are answered…[staff] listen.”

The purpose of this visit was to check if the provider had taken actions to address the

findings of our visit on 8 August 2012. The provider had sent us an action plan showing that they had addressed our findings in August. We referred to this action plan, and the report from our previous visit, at this visit. We made a tour of the premises, talked with staff and looked at records of people who use the service. This gave us sufficient evidence of people’s experiences of the service. We therefore did not speak with any of these people during this visit.

From discussion with staff, and from reading people’s care records, we found that people expressed their views and were involved in making decisions about their care.

From a tour of the premises we found that people, staff and visitors were protected against the risks of unsafe or unsuitable premises.

From discussion with staff, and from reading people’s care records, we found that where people were unable to make informed choices about important life decisions their best interests were not always being fully considered.

All the people we spoke with agreed that their privacy was respected. They described good levels of contact with the local community and felt that a range of suitable activities were offered by the service. One person told us, “I like puzzles.” People told us that their clothes were well laundered and we were able to confirm this from their appearance.

The people we spoke with had little recall of being involved in developing their care plans. However, they all confirmed that staff encouraged them to be as independent as possible.

People told us that staff respected their personal preferences. One person told us, “I get up and go to bed when I want.” They also felt that their needs were met at Hollybank House. People told us that they felt safe living at Hollybank House and that staff showed them respect and ensured their dignity was maintained. They said that staff were competent at their job and that there were normally sufficient staff to meet their needs.

People thought the quality of the service they received was good. One person said, “I can say what I want to say…they will listen to me.” They confirmed they had been asked what they think of living at Hollybank House – in questionnaires and at residents’ meetings.