This inspection took place and was announced on the first day. At the last inspection in August 2016, the service was rated ‘Requires Improvement’ overall. Significant improvements had been made since the inspection prior to that in March 2016 but some additional improvements were still needed and we needed to see that the positive changes that had been made were sustained.

At this comprehensive inspection we found that the registered manager had acted to address the previous issues and where previous improvements had been made, these had been sustained.

Holly Grange Residential Home 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.

The service accommodates up to 19 people in one adapted and extended building. At the time of inspection there were 13 people receiving care in the service. 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.

People were kept as safe as possible in the service. Health and safety and service checks were carried out and action had been taken to address any shortfalls found. Potential risks to people were assessed and action taken to minimise them. People themselves felt safe there. Specialist equipment was available to assist people with limited mobility.

People’s needs were assessed and they were involved in planning their care as much as they were able and wished to be, together with their representatives, where appropriate. People’s wishes with regard to end of life were explored with them and recorded.

People’s rights and freedom were maintained and staff supported their dignity and privacy. People’s individual and diverse needs were identified and provided for. Information was provided in accessible formats where necessary. People’s views about the service were sought via annual surveys and periodic resident’s meetings. People were supported to have maximum choice and control of their lives and care staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice .

People felt the staff were kind, caring and listened to them. People knew how to complain and any complaints made were addressed. A range of activities and entertainment was provided which people could choose whether or not to join in with.

The service liaised effectively with external healthcare services to ensure any more complex needs were met. People’s nutritional and hydration needs were monitored and met. People had been consulted about the meals provided.

Staff received thorough induction training and attended ongoing training updates to maintain their skills. They were supported through regular supervision, annual performance appraisals and periodic team meetings.

The registered manager had systems in place to monitor the operation of the service and plans for ongoing improvements which were being actioned.

This inspection took place on 8 and 9 December 2016. The inspection was unannounced. The service was last inspected in March 2016. At that inspection we found the service was in breach of eight regulations. The service was rated ‘inadequate’ and issued with ‘warning notices’ against regulations 12, 15 and 17 of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014. The service was placed in ‘Special measures’ which meant it was subject to ongoing monitoring to ensure improvements were made.

We carried out a focused inspection on 11 August 2016 to ensure the requirements of the three warning notices had been met. We found the registered manager had taken, or was in the process of taking, action to address all of the areas identified within the warning notices.

This inspection, carried out 8 and 9 December 2016, was a comprehensive inspection to follow up all of the previously identified breaches of regulations and make a judgement about the overall compliance of the service. We found the service had made sufficient improvements that it was now compliant with regulations and could come out of ‘Special measures’. However, there remained a need for further developments in some areas and it was too soon to be sure that the recent improvements would be sustained. We will monitor this at subsequent inspections.

Holly Grange Residential Home is a care home without nursing that provides care for up to 19 people with needs relating to old age. Twenty four hour support is provided by a small regular team of staff. At the time of this inspection, eleven people were receiving support.

A registered manager was in place as required in 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.

People felt safe and well cared for by the staff and that they were consulted and involved in decisions about their care. They confirmed their views about the service had been sought and felt the registered manager was accessible.

Health and safety checks and servicing had been carried out as required with the exception of testing of mains electrical circuits, which was overdue. The registered manager was in the process of arranging for the required testing to be carried out. Other health and safety and fire safety matters had been addressed.

Staff were aware of their responsibilities and how to keep people safe from abuse. No new safeguarding issues had arisen since the last inspection.

People's risk assessments had been improved to address identified risks to individuals and an emergency contingency plan for foreseeable emergencies was in place. People’s medicines were well managed on their behalf when they were unable to do this for themselves.

The service had a robust recruitment procedure in place. However, ongoing recruitment of permanent staff was still proving difficult and significant numbers of agency staff were needed to provide support.

Staff supported people’s day to day health, nutritional and care needs effectively. People were treated with respect and the rights and dignity were supported. People’s preference regarding the gender of staff providing intimate personal care were sought and respected.

Staff induction and training had been improved. The registered manager had attended training to enable him to complete competency assessments for staff working towards the ‘Care Certificate’. Support and development of staff had been improved through the commencement of a new supervision and appraisal programme.

The level of activities and entertainment had been improved but there remained room for further development in this area to maximise the social and emotional support provided.

We have made a recommendation that the ser

Holly Grange Residential Home provides accommodation for up to 19 older people who require personal care support. The home is situated in the village of Cold Ash, near Newbury.

A registered manager was in place as required. 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 inspection took place on 11 August 2016 and was carried out by one inspector. We gave short notice of this inspection because we needed to ensure the manager would be present to assist us.

At the previous inspection in March 2016 we found significant breaches and concerns across eight regulations. As a result we issued warning notices regarding three regulations. When we carried out this focused inspection we found that the registered manager had taken or was in the process of taking action to address all of the areas identified within the warning notices. Sufficient action had been taken that the warning notices had been complied with. We found no new or continuing breaches of the regulations.

This was a focused inspection specifically to check whether the issues identified in the warning notices, following the previous inspection, in March 2016 had been addressed. As a result, the overall rating for this service remains ‘Inadequate’ and the service remains in ‘special measures’.

A further comprehensive inspection will be carried out in due course to review the service’s compliance across all areas and review the rating in order to decide whether the service will come out of ‘special measures’.

Holly Grange Residential Home is a small home which usually only accommodates up to 16 people with needs relating to old age. Three further beds are available which would only be used where people specifically wished to share. The service does not provide nursing care.

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.

People were potentially at risk because staffing levels within the service during the day and at night, were not sufficient to meet people’s needs and some staff were working excessive and potentially unsafe hours. Staff rotas were either inaccurate or were not available to establish who was scheduled to be on duty.

Staff were not properly inducted, supported or trained to ensure they had the necessary skills to meet people’s needs.

The service did not always provide safe care and treatment. A number of health and safety and fire safety risks had either not been identified, or had been identified but not addressed. There was no evidence that necessary safety checks, such as of bath/shower water temperature, had taken place. Some moving and handling equipment was unsafe and some safety equipment was missing, located inappropriately or not regularly tested. These issues placed people at risk of potential injury.

Care plans and other records sometimes lacked sufficient detail, contained conflicting information or had not been updated effectively to make the current information readily available to staff to meet people’s needs. Where risks to people had been identified, this was not always reflected in the care plan with details of the actions staff needed to take to minimise the risk of harm. Inaccurate skin integrity risk assessments placed people at risk of not receiving appropriate care.

There was no evidence of follow up with regard to injuries noted on body charts, in order to identify the cause and any necessary actions to reduce the risk of recurrence.

People were not always kept safe. On one occasion we found the front door open and unsecured, meaning that people could have left the service unobserved or unauthorised people could have gained access to the building.

Some additional fire safety equipment and written guidance regarding evacuation in the event of fire was required and the service had no contingency plan in the event of foreseeable emergencies.

People were placed at potential risk of infection. The service did not have appropriate equipment to sterilise commode pots.

No Legionella testing of the water supply had been carried out to ensure the water supply was free from this hazard.

Support provided to people with their medicines was not fully compliant with national guidance. This meant people may not receive their medicines in accordance with their wishes or in a consistent way in the absence of clear guidelines.

The registered manager did not have a clear understanding of the legislation around people’s rights, freedom and consent. It was not clear whether, or to what degree, people had the capacity to make decisions for themselves, or who had the right to do so lawfully on their behalf. It was not clear whether some people should be safeguarded under the Deprivation of Liberty Safeguards associated with the Mental Capacity Act 2005.

Some equipment had been, or was being used, which could potentially restrict people’s liberty. It was not clear whether appropriate consultation had taken place to ensure that consent was obtained or the decision had been made in the person’s best interests.

People were not always treated with respect and dignity, their views had not always been sought and their wishes were not always respected. At times staff failed to knock on

An adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well led?

As part of this inspection we spoke with four people who use the service, the relatives or friends of three other people, the manager and two staff. We also reviewed records relating to the management of the home which included care plans, risk assessments and other records. We also spoke with a visiting GP and a Community Psychiatric Nurse (CPN).

Below is a summary of what we found. The summary described what people using the service, their relatives and the staff told us and the records we looked at.

Is the service safe?

People received care and support in accordance with agreed care plans which were regularly reviewed and evaluated. People or their representatives were involved in reviews of their care. People’s care plans were completed and up to date aside from the one for the most recent admission which required completion.

Where people had healthcare needs, the home had sought the advice of external healthcare specialists appropriately to maintain their wellbeing and safety. We saw that GP’s, district nurses, CPNs and other external healthcare specialists had been consulted appropriately. The visiting GP and CPN we spoke with were happy with the care they had seen.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the home had liaised effectively with the local authority DoLS team and had made an application under the Deprivation of Liberty Safeguards for one person. The manager was aware of a recent Supreme Court judgement relating to ‘deprivation of liberty’ and agreed to liaise with the local authority regarding its possible implications for other people in the home.

The people, relatives and friends we spoke with were very happy with the service and praised the friendliness of the staff and management.

Is the service effective?

We saw that people’s physical and healthcare needs were met by the staff team. People’s social needs had not been as effectively met because limited activities had been provided to support them to enjoy a fulfilling life. We saw that people enjoyed positive relationships with the staff. The healthcare professionals we spoke with told us the home met people’s needs effectively. The home was said to have worked well with one person in particular to settle them in and improve their wellbeing.

The relatives and friends we spoke with told us that the home was effective in meeting people’s needs. People in the home felt their needs were met.

Is the service caring?

We saw staff working in a caring and respectful way while supporting people. They enabled people to make decisions and choices and gave them time to make decisions. Staff were heard to offer praise and encouragement to the people they were supporting. People could choose where they spent their time and ate their meals and could opt to spend time away from the group.

The people, relatives and friends we spoke with thought the service was very caring. This was reflected in the survey responses received by the home, to date.

Is the service responsive?

We saw that people’s care plans and other documents recorded people’s needs and where these had changed. Care files showed that the home responded promptly to any changes and sought appropriate healthcare advice where necessary.

Care was provided based on people’s known and indicated wishes and preferences. However, people had access to a limited range of meaningful activities to enable them to enjoy a fulfilling life.

People and their relatives felt that they were involved and consulted and that the service responded to people’s needs. The CPN told us the home had worked well with one person to help them settle in, despite them being initially resistant to coming into a care home.

Is the service well-led?

We found that the home provided good care to people and was effectively managed. A limited range of audit and monitoring systems were used by the manager to maintain an overview of the home’s operation. The manager was present daily during the week and oversaw things on a day-to-day basis, without recording this. However, he planned to introduce a new monthly audit tool to provide evidence of this for the future. Action had been taken to address issues where these were identified. The views of people’s relatives were sought and acted upon.

During our inspection in May 2012 people who used the service could not be sure that the provider would tell the CQC about any incidents that affected their welfare and safety. We asked the provider to take action to ensure that people who used the service were protected from such risks. On 19 June 2013, we found that the provider had taken effective action to improve and that people were now protected.

However, the provider did not have suitable arrangements for obtaining the consent of people in relation to the care and treatment they received. People were unaware of their care plans and had not seen their risk assessments. They not been involved in monthly reviews of their treatment and had not signed any records to show their consent or involvement.

People and their relatives praised the quality of care provided. One person told us, “I’m so lucky to be here. I can’t tell you how perfect this place is. I didn’t want to come here but now I feel like it is my home.” The relative of another said, “The staff are so kind and gentle. If he hadn’t come here he wouldn’t be with us today.”

We were told by people that they trusted staff who made them feel safe. Relatives told us that the staff provided excellent care, which gave them confidence in the quality of their training.

People who used the service were protected against the risk of inappropriate care or unsafe care by effective assessment and monitoring of the quality of the service provided.

People told us that staff listened to them and respected their right to make decisions. They told us that their privacy and dignity were preserved at all times. People described the home as ''a very nice place to live'' and a ''very good home''. All seven of the people spoken with individually told us that they felt safe in the home. People told us that staff were wonderful and were always there when needed. They told us that they were always listened to and they would not hesitate to complain if they felt it necessary.

The five relatives of people who lived in the home we spoke with were happy with the care the home provided. They told us that the home consulted health professionals in a timely way. Relatives told us that they were confident their family member was safe. Relatives told us that they felt there were enough staff and that their family members were well cared for. Relatives told us that they were confident to talk to the manager if they had any concerns and were sure he would listen.

People said that they had the support and assistance they needed. People said that they were able to get up and go to bed when they wished and that staff were quick to respond to requests for assistance.

None of the people we spoke with could confirm that they had been involved with the development of their care plans or that they had discussed with staff the care that they needed.

People told us that the meals provided in the home were satisfactory and had improved recently. We were told that if people didn’t like what was on offer they were provided with something else. They told us that they were not involved with the planning and development of meals or menus.

People we spoke with said that they liked living in the home and were happy with their rooms.