Holme Lea

We identified two breaches of legal requirements relating to the management of medicines and the systems for oversight and governance at the service.

We found significant concerns in how the service managed time-sensitive medicines and medicines where doses require regular review. We also found issues with the management of topical creams and record-keeping for the application of creams and thickening powders used in drinks. Improvements had been made in the use of variable-dose medicines and guidance for medicines needed occasionally, such as pain relief. Systems in place to ensure lessons were learnt were not always effectively used. Improvements were needed to care plans, risk assessments and record keeping within the new care planning system. Staff were safely recruited but people did raise some concerns about staffing levels within the home

People were supported to access health care services when needed and there was ongoing work to ensure people’s health needs were met, including work relating to falls and nutrition. Staff asked people’s consent before providing support.

Overall, staff were kind and caring and knew people well. Independence and choice were generally promoted.

People were mostly happy with the support they received and felt staff ensured they got the care they needed. However, care plans and records did not always reflect personalised care, and there was limited evidence that people and their families had been involved in developing care plans. There was also little evidence of support for future planning. One person receiving end-of-life care did not have a care plan reflecting their needs. However, this was quickly addressed by the registered manager.

The registered manager was committed to improving the home. Due to periods of absence, the provider arranged management cover, which led to some inconsistency and gaps in oversight. Processes were in place for audits and checks, and while these identified some issues, improvements in care plans and records had not yet been fully implemented. The oversight systems also failed to identify the most significant risks we found in relation to medicines.