CQC report explained · a residential care home
What the CQC found at The Hollies - Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Staff understood people's risks, medicines were administered safely and there were enough staff to meet people's needs. Inspectors found weaknesses in some health and safety checks, including windows and fire drills, which were addressed or being reviewed.
- Effective?
- Good
- People's needs, dietary needs and healthcare needs were supported well, and staff had suitable training. Some mental capacity records were not detailed enough and systems for monitoring Deprivation of Liberty Safeguards were not robust.
- Caring?
- Good
- Staff were described as kind, caring and respectful. People were involved in decisions, supported to be independent and treated with dignity.
- Responsive?
- Good
- Care plans reflected people's individual needs and preferences. Activities were available, but records did not always show that everyone had been offered the chance to take part, and some information was not easy for people living with dementia to understand.
- Well-led?
- Requires improvement
- Management had made improvements and responded to shortfalls, but quality systems had not identified some safety-check problems. The CQC said management was inconsistent and recommended stronger quality assurance systems.
What inspectors found, July 2023
The Hollies - Care Home is rated Good overall; inspectors found kind, safe care, but management and quality checks still need improvement.
Inspectors visited without notice on 04 July 2023 and 05 July 2023. They spoke with people, relatives and staff, observed care, looked around the home and checked care records, medicines, recruitment files, training, rotas and audits.
The home was rated Good for Safe, Effective, Caring and Responsive. People were protected from abuse, medicines were administered safely, staffing levels were sufficient and care plans were detailed. Inspectors also found kind and respectful staff, good support with food and healthcare, and activities for people to join.
Well-led was rated Requires Improvement. Audits had not found some problems with window checks, fire door checks and fire drill records. Records about mental capacity and Deprivation of Liberty Safeguards were not always detailed or well monitored, and activity records did not always show that people had been offered opportunities to take part.
The overall rating improved from Requires Improvement at the previous inspection in 2021. The provider was no longer in breach of regulations, but the CQC made recommendations about health and safety, mental capacity records and quality assurance.
Kind and respectful care
Inspectors received a lot of positive feedback about staff. People appeared comfortable with staff, and their privacy, dignity and choices were respected.
“Staff were kind, caring and respectful. We received lots of positive feedback from people and their relatives about staff.” from the report
Improved safety
Risk assessments and care plans gave staff detailed guidance. Medicines, safeguarding, recruitment and staffing were judged safe.
“Staff understood risks to people's health, safety and well-being. Care plans and risk assessments were regularly reviewed and contained detailed guidance for staff to follow” from the report
Good support with health and diet
Staff recognised changes in people's health, worked with healthcare professionals and supported people with varied diets and specialised dietary needs.
“Staff worked with and sought advice from healthcare professionals and people's relatives were kept informed.” from the report
Personalised care and activities
Care plans reflected people's needs and preferences. A range of group and individual activities was available, with people's views considered when activities were planned.
“A wide range of group and individual activities were available for people to participate in if they wished, which promoted people's social and mental well-being.” from the report
Progress since the previous inspection
The overall rating and four of the five question ratings improved from Requires Improvement to Good. The provider was no longer in breach of the regulations identified at the previous inspection.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Quality checks missed some safety issues
needs fixingAudits did not identify problems with window checks, fire door safety checks and records of fire drills. The CQC recommended stronger quality assurance systems.
“However, systems had not identified shortfalls in window checks, fire door safety checks and fire drill records.” from the report
Mental capacity records and monitoring
needs fixingSome best-interest records were not detailed enough. Monitoring of Deprivation of Liberty Safeguards applications and conditions was not robust.
“However, systems in place to monitor DoLS applications and authorisations were not robust, and they did not support staff to meet conditions of DoLS.” from the report
Some missed engagement and activity records
minorAgency staff did not always use one-to-one support time to benefit people. Records also did not always show when people had been offered activities.
“We saw agency staff missed opportunities to engage with people and they did not always use this time to benefit people” from the report
Some care information needed more detail
minorInformation displayed for people living with dementia was not always easy to understand. End-of-life care records also needed more person-centred information.
“However, information was not always displayed in a way which could be easily understood by people living with dementia.” from the report
- 01What changes have you made to make sure window checks, fire door checks and fire drill records are complete and accurately audited?
- 02How do you record best-interest decisions and monitor Deprivation of Liberty Safeguards applications, authorisations and conditions?
- 03How do you make sure one-to-one agency support is used to engage the person and meet their needs?
- 04How do you record that each person has been offered activities, including people living with dementia?
- 05What progress has been made on the CQC recommendations since this inspection?
This was an unannounced follow-up inspection of the service after the previous Requires Improvement rating and identified breaches; all five key questions were assessed. This explanation was written from the published report of 29 July 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, July 2021
Requires Improvement; inspectors found continuing risks with safety, medicines and quality checks.
This was an unannounced focused inspection on 27 April, 5 May and 25 May 2021. Inspectors checked Safe and Well-led, including infection control. They spoke with staff and relatives, observed care, and reviewed care, medicines, recruitment and management records.
The home was clean and staff were described as kind and caring. Staffing levels were suitable, staff were trained in safeguarding, and the home had systems for infection control and reporting concerns.
However, risks were not always assessed or reviewed properly. Medicines records and procedures were not always safe. Recruitment and training records were incomplete, and quality checks had not found or fixed all the problems. Some incidents had not been reported to the CQC.
The overall rating remained Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home had also been rated Requires Improvement at the previous inspection, and the report says it had not made enough improvement.
Kind staff
Inspectors found staff to be kind and caring. Relatives also gave positive feedback about the care provided.
“Staff were kind and caring and supported people to achieve good outcomes.” from the report
Suitable staffing
Staffing levels were considered suitable for people's needs. Staff were deployed so communal areas could be monitored for safety.
“Staffing levels were appropriate to meet people's needs.” from the report
Safeguarding
Staff had safeguarding training and concerns had been referred to the local authority.
“Staff were trained in safeguarding and followed processes to report concerns.” from the report
Clean environment
The home was clean and tidy. Many infection prevention arrangements were in place and followed current guidance.
“Staff ensured people lived in a clean and tidy environment.” from the report
Unmanaged risks
seriousSome risks were not properly assessed, managed or reviewed after incidents. Care plans did not always give staff enough guidance.
“Risks to people's safety and wellbeing were not always effectively managed.” from the report
Medicines safety
seriousRecords did not always show that medicine concerns were discussed with health professionals. Covert medicines, as-needed medicines and fridge temperatures were not always managed safely.
“The failure to ensure the safe management of medicines placed people at risk of harm.” from the report
Weak quality checks
seriousThe home's quality systems had not identified or corrected all the problems found by inspectors. Accident and incident information was not always recorded or analysed properly.
“Quality assurance systems were in place but had not identified or addressed all the shortfalls found during the inspection.” from the report
Incomplete staff records
needs fixingSome recruitment, induction and competency records were incomplete. This made it harder to confirm that all checks and training had been fully recorded.
“Induction records were not always in place and competency assessment records were not always detailed.” from the report
Incidents not reported
seriousSeveral older incidents involving allegations of abuse had not been reported to the CQC.
“Several incidents had not been reported to CQC from before the manager started working at the service.” from the report
Isolation delay
needs fixingOn one occasion, isolation arrangements were not put in place promptly after a person returned from hospital.
“We found on one occasion isolation processes had not been implemented for a person following their stay in hospital.” from the report
- 01How have you reviewed and updated every person's risk assessment since the inspection?
- 02How do you now make sure medicine concerns are discussed with GPs or pharmacists, including covert medicines and missed doses?
- 03How do you check that medicine fridge temperatures are recorded and that medicines remain safe if temperatures are outside the permitted range?
- 04How are accidents, incidents and allegations of abuse now recorded, analysed and reported to the CQC?
- 05How do you check that recruitment, induction and staff competency records are complete?
This was a focused inspection of Safe and Well-led, including infection control; the other key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 22 July 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 The Hollies - Care Home
6 rated inspections over 7 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Goodstayed GoodEffective: Good
- February 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 29 November 2010.
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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16 live-in carers within about an hour of East Riding of Yorkshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,420 a week. 14 can care for a couple. 7 years' experience on average.
“She was always 'just present enough': attentive, available, kind and engaging, but without ever over-stepping any boundary”
“What truly stands out is how mindful and attentive she is to all of my medical needs, always going above and beyond to ensure I’m comfortable and well cared for.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.