CQC report explained · a residential care home
What the CQC found at Holly Lodge Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2021
Rated Requires Improvement; inspectors found safe medicines and infection control, but weaknesses in safeguarding, records and management oversight.
This was an unannounced focused inspection after concerns about safeguarding, how allegations were handled and medicines. Inspectors widened the inspection to look at the Safe and Well-led areas. They spoke with staff and reviewed care, medicines, recruitment and management records.
The home was not always safe. Staff concerns were not always investigated or followed up, and care records and risk assessments did not always reflect people's changing needs. Medicines were managed safely, recruitment checks were completed, and infection control arrangements were considered safe.
Management oversight was not consistent. Accidents and incidents were not always reviewed for lessons, and audits had not identified gaps in care records. The overall rating and both inspected areas fell from Good at the previous inspection to Requires Improvement.
Medicines
Prescribed medicines were administered and managed safely. Checks found the medicines examined were accounted for, and staff had training and competency checks.
“People's prescribed medicines were administered and managed well.” from the report
Infection control
Inspectors were assured that infection prevention arrangements were safe, including the use of protective equipment, testing and outbreak planning.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safe recruitment
Recruitment checks were completed before new staff started, including references and Disclosure and Barring Service checks.
“A Disclosure and Barring Service check had been completed before new staff members started their employment, which helped prevent unsuitable staff from working with people who could be vulnerable.” from the report
Family contact
Families were kept informed about concerns and incidents, and were asked for feedback about care.
“The registered manager kept families informed of any concerns and incidents within the service or with their loved one.” from the report
Unresolved concerns
seriousSome staff concerns about care were not investigated further or shared with the local authority. Staff did not always receive feedback after raising concerns.
“These had not been investigated further by the provider and registered manager to make sure people were receiving appropriate care or shared with the local authority.” from the report
Out-of-date care records
seriousRecords and risk assessments did not always reflect changing needs. This created a risk that staff would not have accurate information to provide safe care.
“Care records did not always reflect the care that people needed.” from the report
Weak management checks
needs fixingAccidents and incidents were not always reviewed for lessons, and audits failed to identify problems with care plans and risk assessments.
“However, the issues we found in relation to people's care plans and individual risk assessments not being updated had not been picked up through auditing.” from the report
Missing notification
seriousThe provider did not always inform the local authority or CQC about concerns and allegations of abuse as required.
“A notification of alleged abuse had not been submitted to CQC.” from the report
- 01How have you updated care plans and individual risk assessments when people's needs change?
- 02How are staff concerns and safeguarding allegations now investigated, recorded and shared with the local authority?
- 03How do you review accidents and incidents to make sure lessons are learned and problems do not happen again?
- 04What changes have you made to your auditing system since inspectors found that missing updates were not being identified?
- 05What progress has been made on the action plan requested by CQC after the Regulation 17 breach?
This was a focused inspection of Safe and Well-led after specific concerns; the other key question ratings were not given in this report. This explanation was written from the published report of 13 February 2021 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, January 2020
Holly Lodge Residential Home was rated Good; inspectors found kind, safe care and improvements since the previous Requires Improvement rating.
This was an unannounced inspection on 9 and 10 January 2020. One inspector spoke with people, relatives, staff and a health professional. They observed care and reviewed care, medicine, staffing and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives said they were happy. Inspectors found enough staff, suitable training, personalised care, support with food and health needs, and activities that people enjoyed.
The home had improved since the previous inspection, which was rated Requires Improvement. Risk assessments, care plans and fire safety equipment had been improved. The provider was no longer in breach of Regulations 12 and 17.
There was one missed medicine dose on the day before the inspection. The home contacted the GP and introduced a new system to identify gaps in medicine records. Some end of life plans still needed more detail, and the home was working on this.
Kind and respectful staff
People and relatives described staff as kind and supportive. Inspectors saw staff offering comfort and respecting people's choices and privacy.
“The staff are kind to me and to my friends.” from the report
Improved safety systems
Risk assessments had been reviewed, suitable evacuation equipment was available and staff had practised using it. The provider had addressed key safety concerns from the previous inspection.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Personalised care and activities
Care plans included people's preferences and life histories. People were consulted about activities, and inspectors saw people enjoying exercises, memory activities, music and dancing.
“People had been consulted on what activities they wanted to undertake.” from the report
Good leadership and improvement
The management team carried out checks, supported staff and acted on issues found. The previous concerns about care records, risk assessments and governance had been addressed.
“The provider had addressed the concerns found at the last inspection in that risk assessments, and fire safety equipment was now in place.” from the report
One missed medicine dose
needs fixingOne dose of medicine was missed on the day before the inspection. The home contacted the GP and introduced a new system to reduce the chance of this happening again and to identify gaps quickly.
“There was one missed dose of medication the day before the inspection.” from the report
End of life plans still developing
minorSome end of life plans recorded only that relatives knew the person's wishes and would make arrangements. The home was working to add more detailed information using the My Wishes form.
“Some people's end of life care plans continued to record that their relatives knew their wishes and would take care of arrangements.” from the report
- 01How is the new medicine-checking system working, and what happens if a dose is missed?
- 02How are my relative's risks, including falls and mobility risks, reviewed when their needs change?
- 03How will you record my relative's detailed end of life wishes, including their own choices rather than relying only on relatives?
- 04What activities would be available for my relative, and how would you adapt them to their interests and communication needs?
- 05How would you involve me and my relative in reviewing the care plan and raising any concerns?
This was an unannounced planned inspection covering all five CQC questions, with records, observations and feedback from people, relatives, staff and health and social care professionals reviewed. This explanation was written from the published report of 29 January 2020 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 Lodge Residential Home
5 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- February 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Holly Lodge Residential Home →
- January 2020Goodup from Requires improvementSafe: GoodWell-led: Good
Read what inspectors found at Holly Lodge Residential Home →
- March 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- August 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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