CQC report explained · a residential care home
What the CQC found at Holly House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found enough staff, safe medicines processes and staff who understood safeguarding, but recommended more regular reviews of risks and care plans.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Inspectors did observe kindness and compassion, but no current rating was given for Caring.
- Responsive?
- Good
- This key question was not inspected during this visit. No current rating was given for how the home responds to people's needs.
- Well-led?
- Good
- Leaders and staff knew people well, used audits to monitor the service and involved relatives in care decisions. Staff said communication was effective and they felt supported.
What inspectors found, December 2023
Rated Good; inspectors found safe, kind and well-managed care, with improvements needed to risk reviews and the building.
This was an unannounced inspection on 24 October 2023. One inspector spoke with people living at the home, relatives and staff. They also observed care and checked care, medicines, staffing and management records.
The home supported up to 8 autistic people and 7 people were living there at the time. Inspectors found enough staff, safe medicines systems, suitable safeguarding arrangements and care that respected people's choices, dignity and rights.
The home was rated Good overall. Safe and Well-led were rated Good. Effective, Caring and Responsive were not inspected during this visit, so their previous ratings were used when calculating the overall rating.
Inspectors recommended more regular reviews of risk assessments and care plans. They also recommended a timely programme of decoration and refurbishment because some carpets and parts of the building showed wear and tear.
Choice and independence
People were supported to make choices, live as independently as possible and take part in community activities.
“People were supported to make choices. They had opportunities to be part of the community.” from the report
Kind and respectful care
Inspectors saw staff treating people with kindness and compassion. Relatives spoke positively about the care and support given.
“Relatives said staff were kind, caring and supportive of people and their families.” from the report
Safe medicines support
Staff followed systems for prescribing, giving, recording and storing medicines. They also followed principles aimed at avoiding unnecessary over-medication.
“People were supported by staff who followed systems and processes to prescribe, administer, record and store medicines safely” from the report
Positive leadership
The home used regular checks and audits, and staff said communication was effective and that they felt supported.
“Regular internal checks and audits were completed to monitor service provision” from the report
Wear and tear
minorSome carpets were marked and parts of the building were not well maintained. Inspectors recommended a timely programme of decoration and refurbishment.
“However, not all areas of the home were well-maintained, and there were some signs of wear and tear to the premises.” from the report
- 01How often are each person's risk assessments and care plans now reviewed?
- 02What refurbishment or decoration work has been completed since the inspection, and what remains outstanding?
- 03How do you make sure medicines are regularly reviewed and that unnecessary medication is avoided?
- 04How are people supported to make choices and take part in activities in the local community?
- 05How will you involve relatives when care needs or care plans change?
This inspection covered Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 6 December 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, June 2018
Rated Good; inspectors found safe, kind and personalised care, with some records and decision-making arrangements needing attention.
This was an unannounced inspection on 27 March 2018. One inspector reviewed care records, medicines, staffing, training, maintenance and quality checks. They observed care and spoke with one person, staff and relatives.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, suitable recruitment checks, trained staff, safe medicines practice and detailed care plans.
People appeared comfortable and safe. Staff knew people well, treated them with dignity and supported their choices, communication, interests and community activities. The home had a relaxed and friendly atmosphere.
At the previous inspection in January 2016, staff supervision was not regular enough and this was a breach. Inspectors found this had been improved and all legal requirements were being met. They also noted some outstanding improvements, including a missing listening-device protocol and care records that were not all up to date.
Kind, respectful support
Staff were patient and compassionate. They asked permission before tasks, respected privacy and understood how people communicated.
“We observed staff providing support with compassion and kindness.” from the report
Personalised care
Care plans described people's routines, preferences, communication and support needs in detail. Staff knew this information well.
“People's care records were detailed and personal to the individual.” from the report
Safe staffing and training
Inspectors found enough staff on duty and a broad training programme, including support for autism, swallowing difficulties and distressed behaviour.
“There were enough staff available to provide individual care and support to each person.” from the report
Community involvement
People were supported to follow hobbies, go out, use local services and keep in touch with relatives. Some people also went on holiday with staff.
“They all went out and spent time in the community.” from the report
Improved staff supervision
The previous problem with regular staff supervision had been addressed. Staff now received regular supervision, induction and appraisal.
“Improvements had been made as all staff received regular supervision.” from the report
Listening-device guidance
needs fixingThere was no written protocol for listening devices used when some people spent time in their bedrooms. The manager said this was being addressed.
“A written protocol was not in place for the use of any listening devices which were used to keep people safe” from the report
Some care reviews were late
needs fixingNot all evaluations and reviews of care records were up to date. The manager said extra support was being provided to address this.
“Records we looked at showed not all evaluations and reviews were up-to-date.” from the report
Financial conflict of interest
needs fixingThe organisation managed the finances of four people while also providing their care. The provider recognised this was not independent and said plans were being made to change it.
“It had been recognised by the provider this was a conflict of interest” from the report
Best-interest decisions
minorInspectors advised that best-interest decisions should cover personal care and appropriate gender arrangements, to protect privacy and dignity.
“We advised best interest decisions should be made with regard to people's personal care and support requirements.” from the report
- 01What has been done to create a written protocol for listening devices, and how are people's privacy and dignity protected when they are used?
- 02Are all care-plan evaluations and reviews now up to date, and how often will they be checked?
- 03Has the organisation stopped managing the finances of people whose care it provides, and who now provides independent oversight?
- 04How are best-interest decisions recorded for personal care, including people's preferences about the gender of support workers?
- 05What physical changes have been made to the older building since the inspection?
This was an unannounced inspection covering all five CQC questions and the overall rating; inspectors reviewed selected records and observed care, rather than every person's care. This explanation was written from the published report of 13 June 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 House
3 rated inspections over 8 years: the service has held its Good rating throughout.
- December 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 2011.
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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46 live-in carers within about an hour of Sunderland
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 £950 to £1,210 a week. 42 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
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.