CQC report explained · a residential care home
What the CQC found at Holly Hall House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- The home had effective arrangements for PPE, testing, visiting, social distancing and managing possible outbreaks. Inspectors found damaged and rough surfaces, rust, limescale and flooring defects that made proper cleaning difficult.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, March 2022
Holly Hall House was inspected but not rated; infection control was mostly well managed, but some surfaces and fixtures were difficult to clean.
This was a targeted inspection on 17 February 2022. One inspector visited with 24 hours' notice to check infection prevention, visiting arrangements and staffing pressures linked to COVID-19.
Inspectors were assured about visitors, social distancing, personal protective equipment, testing, admissions and plans for managing outbreaks. People could keep in touch with relatives through visits, phone calls and social media.
Inspectors were only somewhat assured about the cleanliness of the building. They found damaged, rusty or rough surfaces, limescale and flooring and sealant problems that made proper cleaning difficult. The service was inspected but not rated, so this report does not provide a full quality rating.
Visitor infection controls
Visitors were asked to take a lateral flow test and have their temperature recorded. Visiting arrangements followed the guidance in place at the time.
“The provider was following best practice guidance in terms of ensuring visitors to the home did not spread COVID-19.” from the report
Protective equipment
Staff were following PPE guidance and supplies were available in several places around the home.
“Staff were adhering to personal protective equipment (PPE) guidance and practices.” from the report
Family contact
People were supported to stay in touch with relatives through visits, phone calls and online contact.
“People were supported to keep in contact with their family members through social media, phone calls, physical visits, or driveway and garden visits.” from the report
Plans for self-isolation
The home had plans for people who might need to self-isolate and arrangements for safe hospital visits and returns.
“Clear plans were in place for people who may be required to self-isolate.” from the report
Difficult-to-clean areas
needs fixingInspectors found damaged, rough or rusty surfaces, limescale and gaps in flooring and sealant. These defects made proper cleaning more difficult, and the issues had been referred to maintenance.
“These issues made proper cleaning difficult.” from the report
- 01Which of the damaged, rusty or rough surfaces identified by inspectors have now been repaired or replaced?
- 02How do staff clean the areas that inspectors said were difficult to clean?
- 03How does the home check that limescale, rust, flooring gaps and damaged sealant do not create infection risks?
- 04What visiting, testing and PPE arrangements are currently in place?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it was not a full inspection of all five quality areas and the service was not rated. This explanation was written from the published report of 11 March 2022 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, February 2019
Rated Good; inspectors found safe, kind and person-centred care, with earlier medicines and management problems improved.
This was an unannounced, comprehensive inspection on 17 January 2019. One inspector spoke with people living in the home, relatives, staff, the manager and the operations director. They reviewed care records, medicines records, staff files, quality checks and other records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitably trained staff, safe medicines management, clean surroundings and appropriate safeguarding arrangements. They also saw kind relationships, respect for privacy, support for choice and regular contact with health professionals.
At the previous inspection in February 2017, the home was rated Requires Improvement because medicines management, medicines records and quality checks needed improvement. Inspectors said these areas had improved by this inspection. They did still identify a few overwritten medicines records, missing evidence about when staff references were received and a medicines audit that did not check the quality of recording.
Kind relationships
Inspectors saw warm and respectful relationships between staff and people. People appeared happy and staff supported privacy and dignity.
“Interaction between people and staff members was kind, friendly, and naturally caring.” from the report
Choice and independence
People were supported to make choices about food, activities and outings. Some people moved around the home and accessed the community independently.
“Seven residents were able to access the community independently and we saw these people going in and out during the course of the day.” from the report
Improved medicines management
The earlier problems with medicines management and recording had improved. Medicines were securely stored and checks showed the recorded balances matched the medicines held.
“We checked the balance of medicines for four people and found that the amount balanced with the records of what medicines people had taken.” from the report
Supportive staff culture
Staff had access to training and supervision and said they felt supported. Inspectors found staff were proud to work for the home.
“We found that staff were proud to work for the service.” from the report
Overwritten medicines records
needs fixingA few medicines records had been amended by overwriting. This made it difficult to tell what the original record said, and the manager agreed to address it with staff.
“On a few occasions records had been amended, by overwriting, making it difficult to determine the record.” from the report
Reference dates not recorded
needs fixingThe home could not show the dates on which staff references had been received. The manager agreed to change the form and process.
“The service could not evidence the date they had received references.” from the report
Audit did not check recording quality
needs fixingThe medicines audit did not include the quality of recording, even though this was an issue found during the inspection. The managers agreed to add questions to the audit.
“We found that the questions on the medication audit did not cover the quality of recording, an area where issues had been identified as part of this inspection.” from the report
- 01What checks now make sure medicines records are never overwritten and remain clear?
- 02How do you record and check the dates when staff references are received?
- 03What new questions were added to the medicines audit, and what have the latest audits found?
- 04How are people's individual choices about food, activities and community access recorded and reviewed?
- 05How are relatives involved in care plan reviews and decisions about changing needs?
This was an unannounced comprehensive inspection covering all five CQC questions and the overall rating. This explanation was written from the published report of 13 February 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.
Every inspection of Holly Hall House
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Registered with the Care Quality Commission on 4 June 2014.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Dudley
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 £980 to £1,230 a week. 88 can care for a couple. 10 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“Knowing Mum was in Corina's care made an enormous difference to us and we knew she was in safe hands.”
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.