CQC report explained · a nursing home
What the CQC found at Holly Tree Lodge EMI Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2021
Holly Tree Lodge was inspected but not rated; inspectors found strong infection control arrangements during the COVID-19 pandemic.
This was a targeted inspection on 16 March 2021. It looked only at infection prevention and control measures during the COVID-19 pandemic. The inspection was announced.
Inspectors found good arrangements for visits, including pre-booking, testing and personal protective equipment. Staff were trained to use protective equipment, and there was enough available.
The home was clean and had a cleaning schedule. COVID-19 testing, checks before admission and procedures for symptoms or positive tests were in place.
The service was inspected but not rated. This report does not provide a full overall judgement on the quality of care.
Safe visiting arrangements
Visits were organised in advance and visitors were tested and required to use protective equipment. The home followed government guidance at the time.
“Visits were pre-booked to ensure they were staggered and the number of visitors to the home was manageable at all times.” from the report
Staff protection
Staff had training in infection safety and using protective equipment. Inspectors saw staff wearing the right protective equipment, and supplies were available.
“Staff were trained on how to keep people safe from the risk of infection and how to use PPE correctly.” from the report
Clean premises
The home had a cleaning schedule and suitable products to help control infection.
“The premises were clean. There was a cleaning schedule in place and suitable cleaning products were used to control the spread of infection.” from the report
Testing and admission checks
The home carried out COVID-19 tests for residents and staff. It also checked that people moving in had recently tested negative.
“Tests for COVID-19 were being carried out in line with government guidance, for both staff and residents.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visits arranged now, and are visitors still asked to complete any testing or wear protective equipment?
- 02How do you check new residents for infection before they move into the home?
- 03How often are staff and residents tested now, and what happens after a positive result?
- 04How is the cleaning schedule checked, and which areas are cleaned most often?
- 05Can you explain which areas of care were not covered by this targeted inspection?
This was a targeted inspection of infection prevention and control measures during the COVID-19 pandemic; it did not provide ratings for the wider areas of care. This explanation was written from the published report of 23 March 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, November 2019
Rated Good; inspectors found kind, personalised care, with minor improvements still needed in medicines storage and some records.
The inspection was unannounced and took place on 30 October 2019. Inspectors spoke with people, relatives, staff and health professionals. They observed daily care, checked the building and reviewed care, medicines, staffing and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe care, kind staff, personalised support and suitable management checks. People’s medicines were given as prescribed, although some storage arrangements could be improved.
The previous rating was Requires Improvement, published in November 2018. The earlier medicines breach had been corrected, and the home was no longer in breach of regulations.
Kind and respectful staff
People and relatives described staff as kind and caring. Inspectors saw staff provide reassurance, respect privacy and support people with dignity.
“People and their relatives told us staff were kind and caring.” from the report
Personalised care
Care plans included people’s life histories, interests and preferences. Staff knew people well and updated plans when needs changed.
“People's care records were detailed and person-centred.” from the report
Safe staffing and risk management
Inspectors saw a continuous staff presence and found risk assessments covering issues such as falls, choking, malnutrition and dehydration.
“We observed there were enough staff available to keep people safe and to meet people's needs in a timely manner.” from the report
Dementia-friendly environment
The home had been refurbished with features intended to help people living with dementia, including clear signs and sensory areas.
“The provider had refurbished the home to make it more dementia friendly.” from the report
Activities and engagement
People could take part in activities that matched their interests. Staff also spent time talking with people and helping them stay occupied during the day.
“Staff supported people to remain engaged and meaningfully occupied with different activities.” from the report
Medicines awaiting disposal
needs fixingSome medicines awaiting disposal were not kept in a tamper-proof container. Inspectors described this as a minor improvement, and the home was not in breach at this inspection.
“Some medicines awaiting disposal were not stored in a tamper-proof container, in accordance with good practice guidance.” from the report
Medicine risk records
needs fixingSome medicines records did not include guidance about the fire risk linked to paraffin-based creams and ointments. Staff knew how to manage the risk, but the records could be clearer.
“We identified people's medicines records could be improved by including guidance for staff about the risks associated with the use of paraffin-based creams and ointments, which may present a fire risk.” from the report
Nutritional information
minorThe summary section of some care records did not always contain up-to-date nutritional requirements. The manager agreed to address this after the inspection.
“The summary section of some people's care records needed updating, to ensure it consistently recorded people's up to date nutritional requirements.” from the report
- 01How are medicines awaiting disposal kept in a tamper-proof container now?
- 02How are the fire risks from paraffin-based creams and ointments recorded and explained to staff?
- 03Have all care record summaries been updated with people’s current nutritional requirements?
- 04How will you keep families involved when a person’s care needs or care plan changes?
- 05What registration steps has the new manager taken with CQC?
This was an unannounced planned inspection covering all five CQC questions, following the previous Requires Improvement rating. This explanation was written from the published report of 21 November 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.
Every inspection of Holly Tree Lodge EMI Care Home
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Holly Tree Lodge EMI Care Home →
- November 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Holly Tree Lodge EMI Care Home →
- November 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2018Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- August 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2015Inspected but not ratedSafe: Requires improvementEffective: Requires improvement
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2013
Registered with the Care Quality Commission on 3 September 2013.
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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