The inspection took place on 12 and 13 July 2018 and was unannounced. The service was last inspected on 14 July 2015 when we rated the service ‘good’ overall and in all the five key questions. At this comprehensive inspection we have rated the service 'good' overall but rated the safe question as ‘requires improvement.’

Hollymere House is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Hollymere House provides accommodation and nursing care for up to 48 people. At the time of our inspection there were 42 people living at the home.

There was a registered manager 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.

People were complimentary about the care they received at Hollymere House.

There were mixed views about staffing levels. We found that people were receiving appropriate care, however staff were very busy and there were sometimes delays in meeting people's needs. The management team were reviewing staffing levels and the deployment of staff. Recruitment of new staff was underway.

Checks were carried out during the recruitment process to ensure only suitable staff were employed.

Risks associated with people's care and support needs were assessed and guidance was in place to support staff to keep people safe. However, we noted that people did not always have access to their call bells.

Overall medicines were managed safely. However, we found some minor shortfalls in medicines management.

Staff understood their duty to protect people from harm and abuse. Appropriate procedures were followed to report any safeguarding concerns.

The home was clean and well maintained.

People were supported by staff who were suitably trained and supervised.

The registered manager and staff were aware of their responsibilities and acted in accordance with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards. (DoLS).

People's nutritional and healthcare needs had been assessed and were met. People were positive about the food on offer and staff supported people to have sufficient to eat and drink. Staff were responsive to changes in people’s physical and mental health needs.

Overall, staff were caring and treated people with dignity and respect.

We found that people's oral hygiene needs had not always been addressed.

Care plans addressed each person's individual needs, including what was important to them, and how they wanted to be supported. However, daily records were not always complete and accurate. This was being monitored by the management team.

People could take part in a range of activities. They were cared for in a way that took account of their diversity and values. People's end of life wishes were discussed and recorded.

People told us that they felt able to raise any concerns or complaints, however the provider’s complaints procedure was not clearly displayed at the home.

The registered manager understood his responsibilities and had built effective links with other professionals. He had a vision for the service and told us that since coming into post a number of changes have been implemented to make improvements to the care provision.

Staff told us that the manager was approachable and supportive, but some staff felt their concerns were not always acted upon. People and relatives were positive about the management of the home.

The provider had effective systems in place to monitor the quality of the service and ensure that areas for improvement were identified and addressed.

Hollymere House provides accommodation for up to 48 people who need support with their personal care and/or have nursing needs. Accommodation is arranged over two floors, there is a passenger lift to assist people to get to the upper floor. A dining room and communal areas are situated on both floors. On the day of our visit 47 people were living in the home.

At our last inspection of this service in November 2013, we found that people were not always safe and did not always have their health and welfare needs met by sufficient numbers of staff.

Following the visit the Care Quality Commission (CQC) received information that there was an increase to the staffing numbers on duty. Following this the provider sent us an action plan telling us about the improvements they intended to make.

We noted improvements to the home during this inspection and evidence to show the compliance actions had been met.

During our visit we found that increased staffing levels had been maintained.

People told us that they felt safe living in the home, we saw that call bells were responded to promptly and those who needed it were supported to eat and drink.

The service has 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. We found the registered manager accessible and approachable. Staff, people living in the home and relatives told us that they felt able to speak with the manager for guidance or to raise concerns.

We saw that people’s needs had been assessed and care plans provided staff with information how people’s care and support should be met. Staff knew the people they were supporting and provided personalised support.

People were treated with kindness and compassion, staff spent time speaking with the people they were supporting and engaged in light-hearted banter when appropriate.

During our visit we spoke to nine service users, four members of staff, the manager and a relative. The majority of the service users commented that the home was clean and that they were happy living there. However two service users were not happy living there. One service user expressed dissatisfaction at not getting any physiotherapy, whilst another missed home. The relative we spoke to expressed mixed views around if it was a good place for their relative to stay.

We spoke to nine people who used the service, two of which told us they were not offered choice. One service user said staff ''are supposed to wake me up at 7am but don't''. We also spoke to one relative who didn't think that choice was offered. The relative advised that this was because the night staff had to get some service users up before they left in the morning so they were in a rush. The relative explained that this meant that shower’s/baths did not always get offered to people. We read staff meeting minutes that made reference to getting service users up and putting them to bed and the need to maintain choice. One of the four staff that we spoke to told us that the service users had to be put to bed and got up by a certain time. The member of staff pointed out that this was not what it is about and mentioned the word institutionalised, concluding that the service users should be offered more choice.

Seven service users, one relative and two specialist staff that we spoke to all expressed concerns about staffing. The specialist staff also advised us that they had raised concerns regarding fluid balance documentation, staffing and on the numbers of high dependency service users been discharged from hospital for end of life care at the home. During the visit we also witnessed a service user shouting for help to use the toilet, but the carers were busy with other patients so were unable to attend.

Information we received during the visit demonstrated that there were policies and procedures in place to ensure the care and welfare of the service users and that their safety was ensured. The staff at the home provided us with information which showed us that staff employed to work at the home were registered, skilled and experienced staff. They were also able to provide details of regular audits that took place to monitor and improve their services and care.

In this report the name of a registered manager appears who was not in post and not managing the regulated activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time of the visit.

During our visit we saw that care was unhurried and that staff treated people with respect and maintained their dignity.

The relationships between staff and people who lived in the home were warm and we saw that people were relaxed in the company of staff.

Relatives told us they had no concerns or worries about the care and support offered to their family members.

The provider may wish to note that there was little evidence to show that people who used the service and/or their relatives were involved in developing or reviewing the plans of care.

The staff members we spoke with were able to show they were aware of the needs of the people who lived in the home and that they were able to support people with these needs.

We have not received any information of concern from health or social care professionals about the safety and well-being of people who lived in the home.

Information provided by the manager during this inspection told us there were policies and procedures in place to safeguard people who used the service from harm or possible abuse.

The manager for the home provided us with information which showed that staff working in the home received training on safeguarding vulnerable adults.

We saw records which showed that checks were carried out to ensure the health and welfare of people who lived in the home was maintained.

We saw that that personal records for people who used the service were not kept secure and confidential.