CQC report explained · a residential care home
What the CQC found at Holly Cottage
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2019
Rated Good; inspectors found safe, kind and personalised care, with only minor environmental issues noted.
This was an unannounced inspection on 8 May 2019. One inspector spoke with one person and four staff, observed care, and checked care, medicines, recruitment and management records. Information from the local authority was also considered.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable training, respectful care and support for people to make choices, keep relationships and enjoy activities.
The home had improved since the previous inspection in May 2018, when it was rated Requires improvement and had breached Regulation 11. That breach had been addressed. Inspectors noted a small number of painted surfaces needing attention and mild urine odours in two areas.
Safe staffing
Inspectors found enough staff to keep people safe and respond promptly. Staff had time to provide care without rushing.
“There were enough staff on duty to keep people safe.” from the report
Kind and respectful care
Staff understood how people communicated, including when they could not speak or hear. They promoted dignity, choice and independence.
“People were supported by staff to maintain regular contact with families and friends.” from the report
Personalised support
Care plans included people's needs, preferences, routines and interests. People were supported to use local services and enjoy activities they chose.
“People's care plans were detailed and contained clear information about their specific needs, their personal preferences, routines, likes, dislikes and what was important to the person.” from the report
Improved management
The home used audits, care reviews and incident information to improve care. Staff said they felt supported and valued.
“Information from the quality assurance system, care plan reviews and incidents was used to inform changes and improvements to the quality of care people received.” from the report
Lingering odours
minorInspectors noticed a mild lingering urine odour in two small areas. Carpet cleaning had been increased, and changing the flooring was being considered.
“We noted in two small areas of the home that there was a mild lingering odour of urine.” from the report
Paintwork needing attention
minorA small number of painted communal surfaces needed repair. The registered manager acted promptly and later provided photographs showing the work had been completed.
“We identified a small number of painted surfaces in communal areas which needed attention.” from the report
- 01What further action has been taken about the urine odours, and has any flooring been changed?
- 02How will you assess and support my relative's ability to make decisions under the Mental Capacity Act?
- 03How often will my relative be supported to go out and use community facilities?
- 04How will you make sure my relative's care plan reflects their changing needs, preferences and communication style?
- 05What training and supervision will the staff supporting my relative receive?
This was an unannounced inspection that assessed all five CQC questions and included the premises, care provided, records, staff and management systems. This explanation was written from the published report of 8 June 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2018
Rated Requires Improvement; inspectors found kind care and enough staff, but risks, consent records and care plans were not consistently managed.
This was an unannounced inspection on 6 March 2018. Inspectors observed care, medicines, activities and mealtimes. They spoke with people, relatives, staff and the manager, and checked care plans, medicines records, incident records, staff files and quality audits.
The home had enough staff, safe medicines practices and a clean environment. Staff treated people with kindness, respected their privacy and supported contact with relatives. People had activities, healthcare support and choices about food and where to eat.
Inspectors found important gaps. Some risk assessments and care plans had not been updated when people's needs changed. Mental capacity and consent decisions were not always handled lawfully. Audits had not found these problems. The home was rated Requires Improvement overall, with Caring rated Good and the other four areas rated Requires Improvement.
Kind, respectful staff
Staff knew people well and were observed interacting with them kindly. They respected privacy and dignity during personal care.
“People were supported by staff that knew them well.” from the report
Enough staff
Inspectors found staffing levels suitable for people's needs. Staff responded promptly when people needed help or reassurance.
“We found the staffing level was appropriate to ensure that there were enough staff to meet people's needs safely.” from the report
Safe medicines practice
Medicines records had no gaps, staff were trained and medicines were stored securely. A small number of signing errors were corrected during the inspection.
“People received their medicines safely.” from the report
Clean environment
The home was clean and infection-control arrangements were in place. Some areas still needed refurbishment and redecoration.
“The home environment was clean with no malodours.” from the report
Activities and relationships
People had activities linked to their interests and were supported to keep in touch with relatives and use community facilities.
“People had access to a range of activities that reflected people's needs and interests.” from the report
Out-of-date risk assessments
seriousSome risk plans had not been reviewed for several years. One person's mobility had changed, but their behaviour support plan still described support they could no longer use.
“However, not all of these plans had been updated regularly, and for some people no longer reflected their needs.” from the report
Consent and mental capacity
seriousSome decisions were made without recorded capacity assessments or best-interest decisions. In one example, a staff member signed consent for treatment without the legal authority to do so.
“The management of best interests decisions and assessments of people's mental capacity was not always undertaken in line within the framework of the MCA.” from the report
Care plans not kept current
needs fixingCare plans had not been updated during the first four months of the new provider running the home. People and relatives were not routinely involved in care planning.
“Care plans had not been reviewed and updated to ensure they reflected people's changing needs.” from the report
Audits missed problems
needs fixingThe home's checks did not identify the out-of-date care plans and missing consent documentation. The improvement plan did not prioritise the most immediate risks.
“However, we saw that the audits did not identify the issues we found during the inspection.” from the report
Medicine recording errors
minorOn two occasions, staff signed in the wrong part of one person's medicines record. The manager acted immediately to clarify where staff should sign.
“on two occasions recently, staff had signed to confirm they had administered one person's medicine in the wrong section of the MAR.” from the report
- 01Have all risk assessments and behaviour support plans been reviewed to reflect current mobility, health and support needs?
- 02How do you assess a person's capacity before making decisions about medicines or treatment?
- 03How are best-interest decisions recorded, and how do you involve legally appointed representatives?
- 04How often are care plans reviewed with people and their relatives, especially after a change in needs?
- 05What checks now make sure audits identify and prioritise the highest risks?
This was an unannounced inspection covering the home, care provided and all five CQC questions, including observations, discussions and records. This explanation was written from the published report of 19 May 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Holly Cottage
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- June 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2017
Registered with the Care Quality Commission on 5 December 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.