About the service: Hollies Nursing and Residential Home is a residential care home that was providing personal and nursing care to 31 people at the time of the inspection.

People’s experience of using this service:

Medicines were not always being managed in line with current best practice.

Care records did not always fully document the care people required and had received.

Systems of governance and oversight were not sufficiently robust to have identified the issues we found in relation to the management of medicines and care records.

Although the provider had a system in place to ensure staff received required training, this had not been followed in the case of one recently appointed staff member.

People told us they felt safe and comfortable in the home. Staff had completed safeguarding training and knew the correct action to take to protect people from the risk of abuse. Staff had been safely recruited and there were enough staff on duty to meet people’s needs. Staff expressed a commitment to ensuring people received high-quality care.

People were cared for by staff who were kind, caring and respectful of their individual needs and preferences. Staff supported people to be as independent as possible. An activity coordinator encouraged people to engage in activities on both an individual and group basis.

People spoke positively about the way the home was run. Staff told us the registered manager had made significant improvements since their appointment in August 2018. These had resulted in an improved staff culture and better communication in the home.

Rating at last inspection: At the last inspection the service was rated requires improvement (published 18 July 2018). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve. At this inspection sufficient improvement has not been made and the provider is still in breach of regulations.

Why we inspected: We carried out this inspection based on the previous rating of the service.

We identified two continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment and good governance. Details of action we have asked the provider to take can be found at the end of this report.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

A comprehensive inspection was carried out at Hollies Nursing and Residential Home on 11,12 and 14 June 2018. The first day of the inspection was unannounced.

Hollies Nursing and Residential Home Limited is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home is a large detached property and accommodates up to 39 older people on two floors. At the time of the inspection there were 30 people accommodated in the home.

According to CQC records, there was a registered manager in place who was also one of the owners of the service. 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. However, during our conversations with this person, they advised us they were not aware that they were registered as manager as they had thought this registration had lapsed when the manager in post at the time of the previous inspection had successfully registered with CQC in 2015. This manager had subsequently left the home in January 2018 when a new home manager had been appointed; this new manager was in post at time of this inspection and was responsible for the day to day running of the home. However, following the inspection they advised us they had tendered their resignation to the providers. The registered manager advised us they would therefore be undertaking the responsibilities of the role with immediate effect.

At the previous inspection in January 2018 we identified three breaches of regulations; these were in relation to the management of medicines, recruitment procedures and systems to monitor the quality and safety of the service. We issued a warning notice in relation to the management of medicines. We also asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective and well-led to at least good. This inspection was undertaken to check whether the required improvements had been made.

During this inspection, we found a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; this was because care plans were not always person-centred. We also identified continuing breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because systems for the safe handling of medicines needed to be further improved and the systems in place to monitor the quality and safety of the service were not effective. We are considering what action we will take in relation to this breach. Full information about the CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

This is the second consecutive time the service has been rated as ‘Requires improvement’.

Although audits were in place in relation to care plans and medicines, these had not been effective in identifying the shortfalls we found during this inspection. Although the provider took immediate action to rectify some of these shortfalls prior to the end of the inspection, it should not have been necessary for CQC to bring these matters to their attention.

Care plans were not always sufficiently personalised or detailed enough regarding people’s diverse needs. We observed an occasion during which care staff did not follow the care plan when assisting a person to mobilise. This meant there was a risk the person might come to harm.

Medicines were not stored at the correct temperature and records relating to the administration of topical creams and ey

This inspection took place on 22 and 23 January 2018. The first day of the inspection was unannounced. The service was last inspected in February 2016 when it was rated Good.

Hollies Nursing and Residential Home Limited is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home is a large detached property and accommodates up to 39 older people on two floors. At the time of the inspection there were 31 people accommodated in the home.

At the time of this inspection the home did not have 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. The registered manager who was in post at the time of the last inspection had left the home in January 2018. A new manager had been in post for four weeks but they had not yet submitted an application to register with CQC.

During this inspection we identified three breaches of regulations. These were in relation to the management of medicines, recruitment procedures and systems to monitor the quality and safety of the service. This is the first time the service has been rated as Requires Improvement.

We found one of the rooms used to store people’s medicines was not clean. Another room used was not fit for purpose and people’s medicines were accessible to non-trained staff. There were no photographs or allergies noted on the medicines administration records for four people; this meant there was a risk people might be given medicines which were not prescribed for them or unsafe for them to take. Staff told us they had not done any recent training in the safe handling of medicines.

We found one person had been appointed to work at the Hollies without completing an application form. Another person’s application form only documented employment details for the previous 10 years. This meant the provider had been unable to verify people’s full employment history.

Although there were systems in place to monitor the quality and safety of the service these had not been sufficiently robust; this had led to some of the shortfalls we identified during this inspection. Some audits had not been completed for several months. Completed audits did not clearly identify who was responsible for addressing any required actions.

We received mixed feedback from people about staffing levels in the home. Staff told us they rarely had time to sit and spend meaningful time with people who lived in the home. Senior staff told us that the increasingly complex needs of people who lived in the home was placing a strain on them due to the additional responsibilities they had for the completion of paperwork, administration of medicines and contact with health professionals. A visiting health professional told us they were concerned about staffing levels in the home. They told us there was a lack of continuity of care due to the reliance on agency nurses.

We have therefore recommended the provider ensures that a recognised tool is introduced to determine how many staff are required on each shift to safely meet the needs of people accommodated in the home.

During the inspection we noted poor practice in relation to health and safety and infection control, with cleaning equipment/signs left in corridors, drinks bottles on handrails and uncovered clean incontinence pads on trolleys. We also noted the door to the sluice was unlocked. This meant cleaning materials were accessible to anyone who entered. In addition, arrangements in the laundry room did not easily support best practice in infection control measures.

We carried out an inspection of the Hollies Nursing and Residential Home Limited on the 4 and 8 February 2016. The first day was unannounced.

Hollies Nursing and Residential Home Limited provides accommodation and nursing and personal care for up to 39 people. There is a separate unit for seven people who are living with dementia. At the time of the inspection there were 34 people accommodated in the home.

The home is a large detached property situated in Clayton Le Moors, Accrington. The home is close to local amenities including a park, shops, library, pubs and churches. There are safe and accessible gardens and parking is available for visitors and staff.

At the previous inspection on 28 May 2014 we found the service was meeting all the standards assessed.

The service was managed by 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. The registered manager had been in post since April 2015 and was registered with the Commission in October 2015.

People told us they did not have any concerns about the way they were cared for. They told us they felt safe and were looked after. Visitors said, “I’m confident I can leave (my relative) here” and “I’ve never seen anything to concern me.” We observed people were comfortable around staff and good relationships between people.

Staff had an understanding of abuse and were able to describe the action they would take if they witnessed or suspected any abusive or neglectful practice. The management team were clear about their responsibilities for reporting incidents and safeguarding concerns.

People felt staff had the right level of skills and knowledge to provide them with effective care and support. They were happy with the care they received. Staff had been recruited safely and additional staff were being recruited to ensure consistent numbers of staff to meet people’s needs in a safe way. People made positive comments about the staff that cared for them. People said, “Staff are kind to me; they are lovely” and “The staff are very good. They work hard and do a good job.”

People’s medicines were managed safely. We found accurate records and appropriate processes were in place and additional training was planned for all staff who were responsible for management of medicines.

We looked at the arrangements for keeping the service clean, hygienic and maintained. A visitor said, “The place is always clean and tidy.” We found the home was clean and odour free. However we noted strong odours in the main lounge and on the dementia unit. We noted some improvements to the home had been undertaken and people were satisfied with the improvements being made. However, we found some areas were in need of attention and without a formal development plan it was difficult to determine what improvements would be made and what the expected timescales for completion would be. We made a recommendation about this.

People told us they enjoyed the meals. One person told us, “The meals are excellent.” The menus and records of meals served indicated people were offered meal choices. People were served drinks and snacks throughout the day. People’s dietary preferences and any risks associated with their nutritional needs were recorded and appropriate professional advice and support had been sought when needed. People’s healthcare needs were met and appropriate referrals had been made to specialist services as appropriate.

All people had a care plan, which had been reviewed and updated on a monthly basis. People were kept up to date and involved in decisions about care and support and some people had been formally involved in the review of their care.

There were opportunities for people to engage

An adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

We also followed up some areas in need of improvement that we found at our last inspection of 27 January 2014. The provider had sent us an action plan advising how they would improve these areas.

During this inspection we spoke with six people using the service, one visitor and the local authority. We also spoke with two care staff, one nurse, the activity coordinator and the deputy manager. We viewed records which included, three care plans and daily care records, policies and procedures, medication records, menus and records of meals served, monitoring records and equipment service records.

We considered the evidence we had gathered under the outcomes. This is a summary of what we found:

Is the service safe?

Assessments of people’s ability to make safe decisions had been recorded (capacity assessments). However, the assessments did not always correspond with information in the care plans which meant it was not clear what level of support people needed. There had been no applications made under the Deprivation of Liberty Safeguards (DoLS). The acting manager said guidance around the definition of a ‘deprivation liberty’ was currently being reviewed and she was aware of the procedure to follow to ensure people were safeguarded.

Appropriate arrangements were in place to manage people's medicines safely. The service had noted some areas for improvement and action was being taken. One person said, “I get my medications on time all the time”.

We found records were accurately maintained, were held securely and were kept in a way that allowed them to be located quickly when required. There were policies and procedures to support staff with their work. However, a number of these had not been reviewed since 2009.

People had access to a range of appropriate equipment to safely meet their needs and to promote their independence and comfort. Records showed that equipment was stored safely and regularly serviced and maintained.

Is the service effective?

We found the care plans contained some useful information about people's preferred routines and likes and dislikes. This should help staff to look after them properly and ensure people received the care and support they needed and wanted.

There were opportunities for involvement in suitable activities both inside and outside the home. People told us, “There is enough going on; we get the chance to do lots of different things", "I go out with staff" and "There are different activities but I can also do what I like to do". This meant people’s activities were tailored to their individual needs and preferences.

People told us they enjoyed the food. Comments included, "I like the meals; they are very nice", "We are offered a choice and they are helping me with healthier eating" and "The food is very good". Staff were aware of people's dietary preferences and were able to provide specialist diets as needed.

We were told there had been no recent complaints about this service. However, we were aware of some concerns that had not been properly recorded. Without clear records it was difficult to determine whether people’s concerns had been taken seriously and whether appropriate action had been taken.

Is the service caring?

We observed staff interacting with people in a pleasant and friendly manner and being respectful of people's choices and opinions. People described staff as “always cheerful” and “lovely people”. People told us they were happy with the care and support they received. Comments included, "I’m looked after; staff are very good" and "It's absolutely brilliant". A visitor said, "It is well above what I expected" and “I am confident my relative’s needs are being met”.

Is the service responsive?

Regular reviews were carried out to respond to any changes in people's needs and to ensure the level of care was appropriate. A visitor told us they were kept up to date with any changes. However, the records did not clearly show people's involvement or discussions with relatives which may result in people not receiving the care they wanted.

The service had good links with health care professionals to make sure people received prompt, co-ordinated and effective care. People's health and well-being was monitored and appropriate advice and support had been sought in response to changes in their condition.

People had been encouraged to express their views and opinions of the service during meetings, customer satisfaction surveys and during day to day discussions with staff and management. There was evidence the service had listened to people’s views and improvements had been made.

Is the service well-led?

The owner was also the registered manager. However she was no longer in day to day control of the home. The home was being managed by an acting manager. The acting manager was supported by the registered manager who visited the home regularly and informally monitored her practice. We were told the acting manager would be making an application to register with the Care Quality Commission (CQC).

Records and discussion showed audits of the various processes and practices were being carried out. There was evidence these systems had identified any shortfalls and improvements had been made.

We received information from the local authority that the service did not have clear records in relation to people’s care and support. At that time we were told the care plans were being updated and that staff had received additional training to support them with this.

We visited the service and looked at three people’s care records. We found the records did not accurately reflect the care and support being given to people and that the ‘audit’ systems were not effective in identifying any shortfalls in the way information was being recorded. This meant people could be placed at risk of receiving inappropriate care.

In addition we noted the provider had not sent us any ‘notifications’ that were needed to help us monitor the service.

We asked the provider/registered person to send us an action plan indicating how, and by when, they would improve the standard of record keeping.

During our visit we spoke with six people living in the home and with two visitors. People told us they were happy with the care and support they received. Comments included, "It's very good here; you ask and it gets done" and "I'm well looked after; they are very kind". A recent survey indicated people were satisfied with the service they received.

We found people's needs were assessed and care, treatment and support was planned and delivered in line with their individual care plan. However we found the records did not always reflect the care that was being given which meant people could be at risk of not receiving the support they needed. People told us there were opportunities for involvement in suitable activities. Comments included, "They arrange things for us to do; I enjoy most things" and "They tell me what's on and if I fancy it I go downstairs to join in".

We spoke with three members of staff. They also told us they received a range of training to give them the necessary skills and knowledge to look after people properly. People made positive comments about the staff team. These included, "Staff are lovely; they are kind and caring" and "Excellent staff".

During this visit we spoke with five people who use services, two visitors and two staff members.

All the people we spoke with told us they were happy with the care and support they

received. Comments included, "I like it here; I am properly looked after" and "I am very well looked after; I couldn't ask for better". People told us they were able to make choices and decisions about the care and support they received. Comments included, "I can get up at a time that suits me; staff ask me what I prefer to do" and "I am asked what I want to do; it is my choice". A visitor told us, "I am happy with the care".

Two people told us they were able to participate in various activities. Comments included, "There is plenty going on and you can join in if you want to" and "We play different games and even have a bit of a dance sometimes".

People were happy with the cleanliness of the home. They said, "They work so hard to keep it clean" and "The cleaner comes in every day and makes sure everything is just so". However whilst we found all areas were clean and tidy, there were still odours present in some areas of the home. The manager told us this was being addressed as part of the ongoing improvement plans for the home.

We found there were sufficient staff to meet people's needs. Everyone we spoke with made positive comments about the staff team. They said, "The staff are very pleasant" and "They always have time for a smile or a cheery word for me". A visitor told us, "There are enough staff. They are very nice and are attentive to people's needs".

People told us they were treated well and had no concerns about the service or with individual care staff. They said they were able to express their views and opinions about how the service was run and were often asked if they were satisfied with the care and support provided.

People who we spoke with told us they were happy with the care and support they received. They told us they were able to make choices and decisions. Comments included, "I get up early and I always have done", "We can choose what to eat", "I prefer to keep my own company and that is not a problem" and "I can sit anywhere I like and have met some lovely people".

People told us they were looked after properly and that staff treated them well. They

said they were often asked if they were comfortable and happy and would be able to

raise any concerns with staff or management. Visitors told us they were "kept up to date" and were able to discuss their relatives care. One visitor told us, "I am always made to feel welcome and can stay for lunch. I treat it like my home".

People were happy with their rooms and told us staff worked hard to keep it "nice and clean". We found all areas of the home to be clean but not all areas of the home were free from odours.

People were happy with the staff team and told us there were sufficient numbers of staff. Comments included, "Staff are smashing", "They could not do any more or any better than they already do", "Marvellous staff" and "Staff are polite and friendly".