Inspectors come down to Clayton-le-Moors nursing home after the resident’s death

A Hyndburn nursing home where a resident died has been assessed as inadequate by inspectors in a judgmental report.

Hollies Nursing and Residential Home Ltd i Clayton-le-Moors, which provides personal and nursing care to up to 31 people, some of whom live with dementia, was visited by inspectors from the Care Quality Commission on 12 and 13 October.

The unannounced inspection was triggered by an incident in which a person was dead, and concerns about the handling of suffocation.

Read more: Accrington nursing home security check was not in place and residents’ care records incomplete

The report read: “The audit was prompted in part by a report of a specific incident, after which a person using the service died. We are conducting further investigations separate from this inspection.”

Inspectors found that the home was ‘not well maintained’ with deficiencies that meant people were at risk of not receiving proper and safe care.

They said: “Individual human risks, including the risk of falls, suffocation and deterioration of people’s condition, were not routinely identified. This meant that measures were not always in place to reduce these risks. Record keeping was generally inconsistent throughout the home with some records that lacked details or were not up to date. “

Specialist medical advice was lacking, according to the inspectors, who added: “Referrals to more specialist advice were missed, such as to the tissue viability nurse to reduce the risk of pressure ulcers worsening.”



Hollie's Nursing Home in Clayton-le-Moors
Hollie’s Nursing Home in Clayton-le-Moors

One major error was “significant gaps in the reporting and handling of accidents and incidents”, while individual fire risk evacuation plans were not reviewed regularly.

The report said: “Reviews were not conducted after incidents, falls or unexplained injuries. Accidents and incidents were not always completely filled out or analyzed to determine if there were any trends or patterns, to prevent recurrence and to ensure people’s safety.”

Medication handling errors were found and the report said: “The provider did not have effective systems for safe and efficient handling of people’s medicines. Controlled drugs were not handled safely. Storage was not safe and the disposal of controlled drugs was not handled safely. There was a risk that they could be abused or mistreated.

“Thickeners used to help people with difficulty swallowing were not recorded correctly. Drug administration times were not consistently recorded for drugs that required specific time intervals between doses, such as paracetamol. Outdated eye drops were in stock with no guarantee of that they were not in use. “

There was no evidence that people had been injured, the report added, but the systems were not robust enough.

A further major flaw was that systems designed to protect against the risk of abuse were poorly developed, with inspectors highlighting a list of “unexplained bruises” and finding that “humans were not always protected from the risk of abuse.”

The report says: “A large number of reportable protection charges had been made by visiting external professionals as these had been missed by the home. We found a record of unexplained bruises which had not been referred for further investigation to the protection team. The interim manager acted immediately during the inspection. “

Staffing was another shortage, the report said, highlighting a “significant turnover of staff” and high levels of agency staff, while staff morale was “low”

Inspectors said: “Staff told us:” We are often short staffed. If an employee calls sick, the senior will contact the agency, but sometimes they can not supply anyone and we lack staff. “

The report stressed that although there was no evidence that anyone had been injured, there were not enough competent, skilled and experienced staff.

Still, inspectors said recruitment records were satisfactory and that a core group of experienced staff had worked hard across the pandemic to ensure continuity of treatment.

Other positive points that were noted were that people were protected from risks associated with the spread of infection, including from COVID-19 and the home was ‘on target to ensure all staff were vaccinated against COVID-19’. Meanwhile, the equipment was serviced and maintained to ensure that it was clean and suitable for use.

Still, the report said since the inspection that the provider was working with local commissioning teams to improve and had hired a new, experienced interim manager while the recordings had been suspended pending improvements and a new action plan had been drawn up.

Inspectors said they had placed the home in “special measures” and warned that if adequate improvements were not made when they returned within six months, the provider could be stopped from running the service.

A spokesman for Hollies Nursing and Residential Home said: “Prior to the recent inspection by the Care Quality Commission, we had already identified issues requiring urgent action and had appointed a new specialist interim manager to monitor significant changes, and recruited new staff to assist. with implementing them.

“At The Hollies, we have always sought to provide a compassionate and caring environment for elderly residents and those suffering from disabling medical conditions, and both family members and residents have appreciated our efforts. But we recognize that the latest CQC report shows, that we have recently failed to maintain our highest standards and we act on their advice to improve the service we provide.

“We have already reviewed procedures and activities throughout the home and developed an action plan to address the concerns that CQC has raised. We have begun to share that plan and changes to our procedures with residents and their families.

“Like many other care and nursing homes across the UK, The Hollies and its staff have been under intense pressure since the COVID-19 outbreak began, but as the CQC report acknowledges, we have maintained infection control and protected residents.

“The report also acknowledges that the team at The Hollies has engaged and worked in partnership with the local commissioning teams to develop an improvement plan for the service.

“Our new specialist interim manager has within a short time provided the employees with the support they need, with clear and efficient management. Staff welcomed the new support structure and told CQC: “It’s moving forward and upward now.” Another commented: “We are gathering better as a team to get back to the heyday.”

“Our overall rating was previously ‘Good’. It is now ‘Insufficient’ and we must sincerely apologize. That rating is simply not good enough, but we are working hard to regain the standards we have been so proud of – the standards that our residents and their families deserve. ”

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