CQC report explained · a residential care home
What the CQC found at Hollybush Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, and there were enough staff to meet people's needs. Medicines and infection control were generally managed safely, although the medicine refrigerator's maximum and minimum temperatures were not being recorded until this was fixed during the inspection.
- Effective?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous comprehensive inspection.
- Caring?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous comprehensive inspection.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous comprehensive inspection.
- Well-led?
- Good
- The home had effective monitoring and auditing systems, a stable staff team and open management. However, people and relatives had not recently been asked for feedback, with the last survey taking place in 2019.
What inspectors found, August 2021
Hollybush Residential Home was rated Good; inspectors found safe, caring support, but records did not always show people's choices about getting up and going to bed.
This was an unannounced focused inspection on 03 August 2021. One inspector spoke with four people living in the home, three staff members, two relatives and a visiting healthcare professional. Records and management systems were also checked.
The inspection followed concerns that people were being woken early, dressed and taken to the lounge, and told to go to bed at 10pm. Inspectors found five people up and dressed before 7am, but found no evidence that anyone was harmed. People, relatives and staff said people could choose when to get up and go to bed.
Care plans, risk assessments, staffing, medicines, safeguarding and infection control were generally well managed. However, records did not always show people's preferred times for getting up or going to bed. The home was rated Good overall, with Safe and Well-led also rated Good.
Only Safe and Well-led were inspected in detail. The ratings for the other three questions came from previous comprehensive inspections.
Kind and approachable staff
People appeared relaxed with staff and could ask them for help. Relatives and staff described the team and management as welcoming, caring and supportive.
“People were relaxed and comfortable with staff and had no hesitation in asking for help from them.” from the report
Safe care planning
Care plans included individual information, risk assessments and guidance for staff. Health monitoring and pressure-relieving equipment were provided when needed.
“Care plans included risk assessments and guidance for staff on how to meet people's support needs.” from the report
Enough staff
Inspectors saw that staff had enough time to support people and engage with them. Staff recruitment and medicines training were also described as safe and appropriate.
“People, relatives and staff confirmed there were enough staff on duty to meet people's needs.” from the report
Clean and infection-aware
The home was clean, with no bad smells. Infection control procedures had been updated during the COVID-19 pandemic and suitable visiting arrangements were in place.
“The building was clean and there were no malodours.” from the report
Open management
The provider investigated the concerns openly and had systems for audits, staff feedback and reporting incidents. Staff said they worked well together and were supported.
“The monitoring and auditing systems were in place and effective.” from the report
Choices were not always recorded
needs fixingRecords did not always state when people preferred to get up or go to bed. This made it difficult to confirm whether people living with dementia had chosen to be up early.
“However, it was not always recorded when people preferred to get up or go to bed.” from the report
Limited recent feedback
minorThe home had not recently asked people and relatives for feedback about its performance. The provider said a new survey would be sent out soon.
“Questionnaires had not recently been given to people and their families.” from the report
Medicine refrigerator records
minorStaff were monitoring the medicine refrigerator temperature but were not recording the maximum and minimum temperatures. The provider corrected this during the inspection.
“However, staff were not able to monitor the maximum and minimum temperature of this refrigerator.” from the report
- 01How do you record and check each person's preferred time to get up and go to bed?
- 02How do you make sure people living with dementia are not woken or moved to the lounge without their choice being understood?
- 03Has the promised feedback survey for people and relatives been completed, and what changes followed from it?
- 04How are maximum and minimum temperatures for the medicine refrigerator recorded now?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive carried over from previous comprehensive inspections. This explanation was written from the published report of 21 August 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, February 2021
Hollybush Residential Home was inspected but not rated; inspectors found strong infection control arrangements during the COVID-19 pandemic.
This was an announced, targeted inspection on 28 January 2021. It focused on infection prevention and control in response to the coronavirus pandemic.
Inspectors were assured that the home was using PPE safely, testing people and staff, following social distancing guidance and admitting people safely. They also found the home clean, with an up-to-date infection control policy.
The home was closed to visitors in line with government guidance. A separate visiting room was being installed in the garden. The inspection was not given a quality rating, so it does not provide a full assessment of the home.
Infection control training
Staff had received training on using PPE and had access to updated online infection control training.
“The registered manager had arranged for all staff to receive training in house on the appropriate use of personal protective equipment (PPE).” from the report
Clean environment
The home was clean and had procedures to reduce infection risks. Its layout supported social distancing.
“The service was clean throughout. There were appropriate procedures to ensure infection control risks were minimised.” from the report
Testing and admissions
People and staff were tested regularly under the guidance in place at the time. People returning from hospital had to have a negative test on the day of return.
“People and staff were being regularly tested in accordance with current guidelines.” from the report
Communication and visiting plans
The manager regularly explained the precautions to people, staff and relatives. A separate visiting room was being installed to support safer visits.
“The registered manager communicated regularly with people, staff and relatives to make sure everyone understood the precautions being taken, and how to keep people safe.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now, and when was the policy last updated?
- 02How are staff trained and checked on the safe use of PPE?
- 03How are people and staff tested when there is a suspected or confirmed infection?
- 04What happens if a new resident returns from hospital or tests positive?
- 05What are the current visiting arrangements, and is the separate visiting room still being used?
This was a targeted inspection of infection prevention and control measures, with Safe inspected but not rated; the other four questions were not covered. This explanation was written from the published report of 18 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.
Every inspection of Hollybush Residential Home
3 rated inspections over 4 years: the service has held its Good rating throughout.
- August 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- October 2019Goodstayed GoodSafe: GoodWell-led: Good
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016
Registered with the Care Quality Commission on 18 May 2016.
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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