CQC report explained · a residential care home
What the CQC found at Hollybank Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection-control arrangements, including testing, protective equipment, isolation and visits. They were only somewhat assured that the infection-control policy and auditing were up to date.
- Effective?
- Good
- This area was not assessed in this targeted inspection.
- Caring?
- Good
- This area was not assessed in this targeted inspection.
- Responsive?
- Good
- This area was not assessed in this targeted inspection.
- Well-led?
- Good
- This area was not assessed in this targeted inspection.
What inspectors found, February 2022
Hollybank Residential Home was inspected but not rated; inspectors found strong infection-control arrangements, with some gaps in staff risk assessments and audits.
This was an announced, targeted inspection on 27 January 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements and COVID-19-related staffing pressures.
The home had arrangements for safe visits, testing, isolation, protective equipment and social distancing. Inspectors observed staff following protective equipment and distancing guidance. Families were kept in touch through calls, emails and virtual or in-person visits.
Inspectors were only somewhat assured that the infection-control policy was up to date. Risk assessments for staff who were more vulnerable to COVID-19 had not been completed, and monthly infection-control audits had not been done since February 2021.
The service was inspected but not rated. This means the inspection did not give a new overall quality rating or full ratings for the five areas of care.
Safe visiting
The home offered video calls and several ways to visit in person, including a designated visiting pod and a conservatory. Visitors had temperature checks and had to show a negative lateral flow test.
“The provider had arrangements for visitors to meet with people in a visiting pod (designated area for visits)” from the report
Protective equipment
Inspectors saw staff following protective equipment and social-distancing guidance. The home had five stations for putting on and taking off protective equipment.
“Our observations during the inspection confirmed staff were adhering to PPE and social distancing guidance.” from the report
COVID-19 controls
The home used testing, isolation, dedicated staff and separate arrangements for people who tested positive. New admissions were tested and isolated in line with guidance.
“All COVID-19 positive service users were isolated according to Public Health England Guidelines.” from the report
Keeping families informed
The provider kept in touch with families and friends through regular phone calls and emails, alongside virtual and physical visits.
“The provider kept in touch with family members and people's friends through regular phone calls and emails.” from the report
Incomplete staff risk assessments
needs fixingAt the inspection, the home had not assessed staff who were more vulnerable to COVID-19 or made plans to reduce risks to their health and wellbeing. The provider later told inspectors these assessments had been completed.
“they had not ensured staff who were more vulnerable to COVID-19 had been assessed and plans were in place to minimise the risk to their health and wellbeing.” from the report
Gaps in infection-control audits
needs fixingMonthly infection-control audits had stopped after a staff member left in February 2021. Earlier audit records also did not clearly show which audit tool had been used. The provider later introduced a new audit tool.
“they had not undertaken their monthly IPC audits since a staff member left in February 2021” from the report
- 01How often are the new monthly infection-control audits now completed, and can families see the latest findings?
- 02How are staff who may be more vulnerable to COVID-19 risk assessed and supported?
- 03What happens if a resident tests positive for COVID-19, including who will provide their care?
- 04How will visiting arrangements work if there is an outbreak or a change in infection-control guidance?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not provide a full review or new ratings for the other areas of care. This explanation was written from the published report of 15 February 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.
What inspectors found, August 2019
Hollybank Residential Home was rated Good; inspectors found safe, kind and personalised care, with earlier fire safety improvements completed.
This was an unannounced inspection on 31 May 2019. One inspector spoke with six relatives and six staff, observed care, and checked care, medicine, recruitment and management records. The home was caring for 17 older people, including 13 people living with dementia.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found that people were protected from abuse, risks were reviewed, medicines were given safely, and there were enough staff during the visit.
Care plans were detailed and based on people's needs and choices. People were supported with food, healthcare, communication, activities, privacy and independence. The overall rating stayed Good, the same as at the previous inspection in 2016.
Managing risks
The home assessed risks such as falls, nutrition and pressure ulcers, and kept these assessments under review. Inspectors saw evidence that falls and pressure ulcers had reduced.
“Risk assessments were kept under review, which ensured that risks to people's safety and wellbeing were monitored and managed properly.” from the report
Safe medicines
Staff had medicine training and competency checks. Records and medicine stocks matched, and staff recorded why they gave medicines when needed.
“Medicines were managed safely in line with national guidance.” from the report
Dignity and independence
Staff gave people time, respected their privacy and supported them to do what they could for themselves.
“Staff maintained people's independence by supporting them to manage as many aspects of their care as they could.” from the report
Support for people with dementia
The environment included familiar objects and areas designed to help people living with dementia understand and engage with their surroundings.
“The environment had been adapted to meet the specific needs of people living with dementia.” from the report
Earlier fire safety work
minorA London Fire Brigade inspection in April 2019 had identified minor amendments to premises maintenance. Inspectors found that improvements had been made by this inspection, with work due to be completed by 15 October 2019.
“There was a system for the maintenance of the premises, however, this had been found to require minor amendments at the inspection that was carried out by the London Fire Brigade in April 2019.” from the report
- 01What improvements were made after the London Fire Brigade inspection, and were all remaining actions completed by 15 October 2019?
- 02How do you check that staffing levels remain enough when people need more help or several staff are busy at once?
- 03How are the needs and preferences of people living with dementia reviewed and reflected in their care plans?
- 04How do you monitor people subject to Deprivation of Liberty Safeguards so that restrictions do not continue unnecessarily?
- 05What activities are currently available for people who prefer individual support rather than group activities?
This was an unannounced scheduled inspection covering all five quality areas, including the premises and care; all ratings remained Good from the previous inspection published in 2016. This explanation was written from the published report of 28 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.
Every inspection of Hollybank Residential Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 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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