CQC report explained · a residential care home
What the CQC found at Holly House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found robust risk assessments, enough staff, safe recruitment and medicines given as prescribed. Infection prevention and control arrangements were also found to be effective.
- Effective?
- Good
- People received suitable assessments, training-supported care and help with food, drink and healthcare. Staff sought consent and the service was meeting the Mental Capacity Act requirements.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors saw respectful interactions and people being offered choices about their daily care.
- Responsive?
- Good
- Care plans were personalised and people had activities and support to maintain relationships. However, care plan reviews did not always show involvement from people, relatives or representatives.
- Well-led?
- Good
- People, relatives and staff spoke positively about the management and culture. Inspectors noted concerns about management cover, the need for more specialist epilepsy training and unclear evidence that all survey feedback had led to action.
What inspectors found, October 2023
Rated Good; inspectors found kind, safe care, but care plan reviews did not always show people's or relatives' involvement.
The inspection was unannounced and took place on 7 September 2023. One inspector spoke with people, relatives, staff and managers. They reviewed care records, medicines records, recruitment files, audits and policies, and observed care and the home.
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, good infection control and effective work with health professionals.
People and relatives described staff as kind and caring. People were supported to make choices, keep their independence and take part in activities. The main shortfall was that care plan reviews did not always record how people, relatives or representatives had been involved.
The overall rating stayed Good compared with the previous overall rating, published in 2017. The Responsive rating fell from Outstanding to Good.
Safe medicines and staffing
People received their medicines safely and inspectors found enough staff to meet people's needs and reduce risks.
“People received their medicines safely and as prescribed and were supported by sufficient numbers of staff to ensure risk of harm was minimised.” from the report
Kind and respectful care
Staff treated people with kindness, dignity and respect. People were offered choices and supported to remain independent.
“We observed kind and caring interactions between staff and people.” from the report
Good staff preparation
Staff had relevant training and new staff received a comprehensive induction with support from experienced colleagues.
“New staff who had completed a comprehensive induction, were well supported and either had health care qualifications or were completing training” from the report
Activities and relationships
People had meaningful activities and were supported to maintain important relationships, including activities in the community.
“People had opportunities to engage in meaningful activities.” from the report
Care plan review involvement
needs fixingCare plan reviews did not always record how people, relatives or representatives had been involved. This was especially unclear for people who lacked capacity.
“Care plan review records lacked involvement from people, their relatives and representatives.” from the report
Management cover
needs fixingThe registered manager also supported another home. Some staff felt this could affect staffing levels when the manager was away, and another deputy was being sought.
“Some staff members felt it could have an impact on staffing levels.” from the report
Specialist epilepsy training
needs fixingStaff had epilepsy training but said some people's needs were complex and more specialist training was needed. The manager said this would be arranged.
“I believe we need more specialist training.” from the report
Acting on survey feedback
minorFeedback was generally positive, but it was not always clear what action had followed people's, relatives' or staff members' comments.
“It was not always clear how the feedback had been acted upon.” from the report
- 01How do you now record people's, relatives' and representatives' involvement in care plan reviews?
- 02What specialist epilepsy training has been arranged, and when will staff complete it?
- 03How is staffing maintained when the registered manager is working at the other home?
- 04What changes have been made in response to staff requests for more epilepsy training?
- 05How will you show that feedback from people, relatives and staff leads to action?
This was an unannounced inspection of all five key questions, including infection prevention and control under Safe, prompted by concerns about the number of people living at the home. This explanation was written from the published report of 11 October 2023 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, October 2017
Holly House was rated Good overall, with Outstanding personalised support and activities, and no breaches reported.
This was an unannounced inspection on 10 July 2017. It was the first rating inspection since the home registered in August 2015. One inspector spoke with people living at the home, relatives, staff, managers and a visitor. Records about care, medicines, staffing, activities, complaints and quality checks were also reviewed.
The home supported up to eight younger adults living with dementia and mental health issues. All eight places were occupied during the inspection. Inspectors found people felt safe, staff were trained and there were enough staff to meet people's needs. Medicines were managed safely and people had access to food, drink and healthcare.
People were described as being treated with kindness, dignity and respect. Inspectors found that care was personalised and that people were supported to stay active, maintain relationships and take part in activities they enjoyed. Responsive care was rated Outstanding. Safe, effective, caring and well-led were rated Good.
Personalised support
Inspectors found that people were central to decisions about their care and daily lives. Staff knew people's preferences, goals and interests.
“People were at the heart of the service and people's expectations were exceeded in relation to the support provided to them.” from the report
Active lives
People were supported to take part in activities that suited their interests, including outings, exercise, holidays and community activities.
“People were provided with a variety of opportunities that met their individual needs, providing them with an enhanced sense of wellbeing and exceptional quality of life.” from the report
Kind and respectful care
Inspectors saw warm relationships between people and staff. Staff supported independence and respected people's privacy, dignity and choices.
“Staff treated people with dignity and respect and encouraged people to maintain their independence.” from the report
Good safety systems
Risks were assessed and reviewed. Staff were trained to identify abuse, incidents were investigated, and medicines were checked.
“People were supported by staff who had received training in how to recognise signs of abuse.” from the report
Some staff needed prompting about legal safeguards
minorStaff understood the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards, but inspectors noted that some staff needed prompting on this subject.
“Staff understood the principles of the MCA and DoLS, but some staff required some prompting on the subject.” from the report
- 01How do you check that all staff understand the Mental Capacity Act and Deprivation of Liberty Safeguards?
- 02How would you maintain safe staffing and continuity of care if there were staff sickness or vacancies?
- 03How are my relative's lifestyle plan, activities and personal goals reviewed with them and their family?
- 04How do you check that medicines are administered correctly and that any missed records are followed up?
- 05How would you keep our family informed about changes in my relative's health or care needs?
This was an unannounced first rating inspection covering all five CQC questions and the overall quality of the home. This explanation was written from the published report of 25 October 2017 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 House Care Home
2 rated inspections over 6 years: the service has held its Good rating throughout.
- October 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- August 2015
Registered with the Care Quality Commission on 13 August 2015.
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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