CQC report explained · a residential care home
What the CQC found at Holly Tree Cottage
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staff recognised distress, but one person's plan was not always followed. Inspectors found that unplanned seclusion and physical intervention had placed the person and staff at risk.
- Effective?
- Requires improvement
- This question was not assessed during the targeted inspection.
- Caring?
- Good
- This question was not assessed during the targeted inspection.
- Responsive?
- Good
- This question was not assessed during the targeted inspection.
- Well-led?
- Requires improvement
- This question was not assessed during the targeted inspection.
What inspectors found, September 2023
Inspected but not rated; inspectors found staff recognised distress, but one person's needs could not be safely met and unplanned restrictions had been used.
This was an unannounced targeted inspection. It looked at how people experiencing emotional distress were supported, rather than the whole service. One inspector visited the home on 24 August 2023 and spoke with people, staff and managers. They also reviewed care plans, incident records, investigations and staff meeting minutes.
Staff usually recognised signs of distress and care plans explained how to respond and avoid restricting people's freedom. Plans for other people inspected were being followed and appeared effective. Staff reported incidents, managers investigated them and staff took part in reviews to learn from what happened.
However, one person's plan had not always been followed. This included a period of seclusion in their room and an unplanned physical intervention without safeguards. Inspectors found that this person's changing needs could not safely be met at the home. The provider was looking for a more suitable service and discussing interim plans.
The service was inspected but not rated because this was a targeted inspection. The previous overall rating was Requires Improvement, published on 13 August 2022, and that rating remained unchanged.
Recognising distress
Staff recognised when people were becoming emotionally distressed. Care plans gave guidance on how staff should respond.
“Staff recognised signs when people experienced emotional distress.” from the report
Support for other people
The plans inspectors checked for other people were being followed and were effective in supporting them during distress.
“Other people's plans we looked at were being followed and were effective in supporting people at times of distress.” from the report
Learning from incidents
Staff reported incidents appropriately. Managers investigated them, shared lessons and held reviews with staff after incidents.
“Staff took part in post incident reviews, after they had supported people experiencing emotional distress.” from the report
One person's needs were not safely met
seriousInspectors found that one person's current and changing needs could not safely be met at the home. The provider was looking for a more suitable service and discussing temporary plans.
“It was evident 1 person's current and changing needs, in relation to their distress, could not be safely met at Holly Tree Cottage.” from the report
Unplanned restrictions
seriousOne person's plan was not always followed. Inspectors found that the person had been secluded in their room and had experienced an unplanned physical intervention without safeguards.
“Unplanned restrictions and seclusion place both the person and staff at risk.” from the report
- 01What interim support plan is now in place for the person whose needs could not safely be met?
- 02What progress has been made in finding that person a more suitable service?
- 03How will you make sure each person's care and support plan is followed during distress?
- 04What safeguards are in place if restrictive intervention or seclusion is considered?
- 05Has the new manager registered with the CQC, and who is responsible for the home until that happens?
This was an unannounced targeted inspection of support for people experiencing emotional distress; it did not assess the whole Safe key question or the other four key questions, so the previous ratings remained unchanged. This explanation was written from the published report of 23 September 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, December 2022
Holly Tree Cottage was inspected but not rated; inspectors found that serious fire and environmental safety problems had been addressed.
This was an unannounced targeted inspection on 13 October 2022. One inspector reviewed documents, toured the home and spoke with staff and a manager by telephone.
The inspection followed a Warning Notice about fire and environmental safety. Inspectors found that the required work had been completed. Fire doors had been replaced where needed, specialist work had been carried out, and safety measures had been agreed with the local fire service.
The home was inspected but not rated at this visit. Its previous overall rating of Requires Improvement remained in place because this inspection did not assess the whole service or all parts of the Safe question.
Fire safety work completed
The home had fixed the fire safety problems identified at the previous inspection. This included replacing fire doors and arranging specialist contractor work.
“At this inspection we found improvements had been made and the warning notice had been met.” from the report
Co-operation with the fire service
The provider had worked with the local fire service to put suitable fire safety measures in place.
“The provider had also worked with the local fire service to ensure appropriate fire safety measures were in place.” from the report
Reduced risk from hot surfaces
Radiators and exposed pipework had been covered to reduce the risk of burns.
“Action had been taken to ensure the environment was safe and people were not exposed to the risk of burns from hot surfaces.” from the report
The wider safety rating remains Requires Improvement
needs fixingInspectors did not assess the whole Safe question, so the previous rating was not changed. This visit therefore gives only limited assurance about safety overall.
“The overall rating for the service has not changed following this targeted inspection and remains requires improvement.” from the report
No registered manager was in post
minorThere was no registered manager at the time of the inspection. A new manager had been in post for six months and was completing an application to register.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How are the completed fire safety works being checked and maintained now?
- 02What arrangements are in place while there is no registered manager?
- 03When will the next comprehensive inspection assess the whole Safe question?
- 04How are radiators and exposed pipework being checked to make sure people remain protected from burns?
- 05What other improvements are being made in response to the previous Requires Improvement rating?
This was a targeted inspection of specific fire and environmental safety concerns linked to Regulation 12; it did not assess the whole Safe question or the other key questions, whose ratings were not reviewed. This explanation was written from the published report of 1 December 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.
Every inspection of Holly Tree Cottage
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- September 2023Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- December 2022Inspected but not ratedSafe: Inspected but not rated
- August 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2020GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2020
Registered with the Care Quality Commission on 1 December 2020.
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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