CQC report explained · a residential care home
What the CQC found at Holly House Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2019
Rated Good overall; inspectors found kind, safe and personalised care, but the home’s quality checks required improvement.
This was an unannounced inspection on 29 July 2019. One inspector spoke with four people, five staff and the registered manager. They observed care and reviewed care, medicine, recruitment and management records.
The home provided accommodation for 10 adults with learning disabilities. Inspectors rated Safe, Effective, Caring and Responsive as Good. They found enough suitably skilled staff, personalised support, access to healthcare, kind interactions and opportunities for people to make choices and use community facilities.
Well-led was rated Requires Improvement. Audits had not always found errors in medicine records, gaps in health and safety checks, environmental issues or overdue staff supervision. The overall rating stayed Good, and the report says the previous overall rating was also Good.
Kind and respectful care
Inspectors saw staff treating people with kindness, dignity and respect. People were involved in decisions about their care and supported to be independent.
“We observed kind and caring interactions between people and staff.” from the report
Personalised support
Care plans recorded people’s needs, choices, goals and preferences. People could choose activities, meals, where to spend time and whether to go into the community.
“Care plans contained current and up to date information. They reflected people's needs and choices.” from the report
Staffing and safeguarding
There were enough staff with suitable skills to meet people’s needs. Safeguarding procedures were in place and staff understood how to report concerns.
“There were enough staff to meet people's needs and keep them safe.” from the report
Quality checks were not robust
needs fixingThe home’s audits did not consistently identify problems or provide a full picture of checks carried out. The report says these systems needed to be embedded and strengthened.
“We found systems used to check the quality of the service needed to be further embedded into practice and made robust.” from the report
Medicine records
needs fixingInspectors found errors in some medicine administration records. These had not been identified by the provider’s medicine audit, although inspectors said people still received medicines as prescribed.
“We found some recording errors on people's medicine administration records which had not been picked up in the provider's audit.” from the report
Building maintenance
minorInspectors found staining caused by a leak on a corridor and in a downstairs bathroom. Some minor infection control issues in a bathroom were corrected during the inspection.
“There had been a leak which had caused staining to the ceiling in a corridor and in the downstairs bathroom.” from the report
Staff supervision
needs fixingStaff had not received regular one-to-one supervision. The registered manager knew this needed attention and planned to address it.
“Staff had not received regular one-to-one sessions of supervision” from the report
- 01What changes have you made so medicine audits reliably identify errors in medicine administration records?
- 02How do you now make sure health and safety audits cover every relevant area of the home?
- 03Are all staff receiving regular one-to-one supervision, and how is this monitored?
- 04Have the ceiling stains caused by the leak been repaired, and what other environmental improvements were completed?
- 05How will you continue to support people to make their own choices, maintain independence and access the community?
This was an unannounced planned inspection covering all five key questions and included a review of restrictive interventions; the home was not providing end of life care at the time. This explanation was written from the published report of 20 August 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, February 2017
Rated Good overall; inspectors found safe, kind and personalised care, but the home’s leadership systems still required improvement.
Inspectors visited on 13 and 21 December 2016. The first visit was unannounced. They spoke with six people, five staff, the manager and the provider, as well as two health professionals. They looked at the home, care records, medicines, staff records and management systems.
People told inspectors they felt safe and were happy with the care. Staff understood safeguarding and people’s risks. There were enough staff, medicines were generally given as prescribed, and recruitment checks had been completed. People received care that reflected their needs and choices, with good access to food, activities and healthcare.
The home was rated Good in Safe, Effective, Caring and Responsive. It was rated Requires Improvement for Well-led because newer checks and action plans had not yet been fully put into practice. The overall rating improved from Requires Improvement at the previous inspection in September 2015.
People felt safe
People told inspectors they felt safe. Staff knew how to recognise and report possible abuse, and risk assessments were in place.
“People who used the service told us they felt safe living at Holly House.” from the report
Respectful care
Staff supported people in a warm and respectful way. Inspectors saw people being treated as individuals, with privacy and dignity maintained.
“Staff respected people's privacy and dignity and spoke to people with understanding, warmth and respect.” from the report
Personalised support
Care plans included people’s needs, preferences and goals. People were involved in their care and supported to become more independent.
“People received personalised support that was tailored to their individual needs and preferences.” from the report
Choice and activities
People could choose what and when to eat, where to eat and who to sit with. They were offered trips, clubs and activities in the home.
“We saw meal times were very flexible and people came in at different times to prepare their meal.” from the report
Improvement since the previous inspection
The overall rating improved from Requires Improvement in September 2015 to Good at this inspection. The home had introduced more robust monitoring systems and an action plan.
“These had been improved since our last inspection, however there was still improvement required.” from the report
Fire escape safety
seriousA first-floor fire escape had rotted wood and was unsafe. This was fixed during the inspection.
“The wood between the door and the metal steps had rotted and was unsafe.” from the report
Medicine records
needs fixingCarried-over medicine amounts were not always recorded correctly. The home identified the errors, completed an audit and arranged staff training.
“However, we saw carried over amounts were not always recorded correctly.” from the report
PRN medicine guidance
needs fixingThere was not always clear guidance explaining why some as-needed medicines were prescribed and what signs should lead to their use.
“However, there was not always a protocol in pace that gave details of the PRN medication to determine what medication was prescribed for” from the report
Management checks
needs fixingEnvironmental audits were not formally documented, and some medicine recording errors had not been found through the home’s own checks. New systems needed to become routine.
“environmental audits had not been formally documented and some medication documentation errors had not been identified.” from the report
Recording best-interest decisions
needs fixingStaff understood the process for making best-interest decisions, but the decisions were not always clearly documented. A new template was being introduced.
“However we found best interest decisions were not always clearly documented.” from the report
- 01How do you now check that medicine amounts carried over between cycles are recorded correctly?
- 02Where can staff find the current guidance for each person’s PRN medicine and the signs that it is needed?
- 03How do you record and review best-interest decisions for people who cannot make particular decisions themselves?
- 04How often are environmental audits completed and where are the results recorded?
- 05What evidence can you show that the new monitoring systems are now fully embedded in everyday practice?
This was an inspection of the overall quality of the home, covering Safe, Effective, Caring, Responsive and Well-led, with the first visit unannounced. This explanation was written from the published report of 21 February 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 Residential Home
4 rated inspections over 4 years: the service has improved, from Inadequate to Good.
- August 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Holly House Residential Home →
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Holly House Residential Home →
- November 2015Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2015InadequateSafe: InadequateEffective: InadequateCaring: GoodResponsive: InadequateWell-led: Inadequate
- November 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 6 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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