CQC report explained · a residential care home
What the CQC found at The Hollies
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found risks from falls were not always managed, staffing was insufficient, medicines were not always managed safely, and infection control arrangements were not always effective. Safeguarding systems and recruitment checks were positive.
- Effective?
- Requires improvement
- This key question was not inspected during this visit because CQC said no areas of concern had been identified.
- Caring?
- Good
- This key question was not inspected during this visit because CQC said no areas of concern had been identified.
- Responsive?
- Good
- This key question was not inspected during this visit because CQC said no areas of concern had been identified.
- Well-led?
- Requires improvement
- Management systems did not reliably identify or deal with problems. Records and policies were incomplete or out of date, and audits had missed concerns about medicines, risks, infection control and staffing.
What inspectors found, October 2021
Requires Improvement; inspectors found serious concerns about staffing, falls, medicines, infection control and management systems.
This was a planned inspection on 16 June 2021. It followed concerns about a serious injury after a fall from stairs. Inspectors observed care, checked records and spoke with people, relatives, staff and health professionals.
The home was rated Requires Improvement overall, and also Requires Improvement for Safe and Well-led. Inspectors found there were not enough staff at times, falls were not always properly investigated or reduced, medicines records and storage were not always safe, and infection control was not always effective.
The home had safeguarding systems and robust recruitment checks. People and relatives generally said they felt supported. However, management checks had failed to identify several problems. CQC found breaches of regulations covering safe care, governance and staffing.
Safeguarding
The home had safeguarding procedures, and staff understood how to report concerns and use whistleblowing arrangements.
“The provider had effective safeguarding systems in place.” from the report
Recruitment checks
Inspectors found appropriate checks were completed to make sure staff were suitable to work in care.
“The provider had robust recruitment checks in place to ensure staff were suitable to work in a care setting.” from the report
Supportive relationships
People, relatives and staff gave positive comments about the management team and support from staff.
“There was an open and positive culture. Staff told us they felt part of a team and were supported by the management team.” from the report
Working with health professionals
The home had established constructive relationships with visiting health professionals.
“The home had established good working relationships with health professionals and received compliments from visiting professionals.” from the report
Not enough staff
seriousCommunal areas were left without staff for periods of time. Inspectors said this increased the risk of falls or physical altercations, and there was not enough staff time for meaningful activities.
“The service did not have enough staff to care for people safely.” from the report
Falls and risk management
seriousThe home reported many unwitnessed falls, but inspectors were not assured that action was taken to reduce the risks. Some incidents had no documented follow-up.
“We were not assured that systems were always in place to take action to reduce these.” from the report
Medicines
seriousMedicines reviews were not adequate. Records were incomplete or unclear, stored medicines records were inaccurate, and some medicines were not stored in line with best practice.
“Medicines were not managed safely.” from the report
Infection control
seriousInspectors saw problems with social distancing, mask use and the accuracy of cleaning records. Old infection control guidance was still being used.
“We were not assured the provider was using PPE effectively and safely, during the inspection we observed staff with face masks worn incorrectly.” from the report
Management checks
seriousAudits did not identify several of the problems inspectors found. Some policies were out of date or had no review date, and records were not always accurate.
“However, our findings regarding medicines, risk management, infection prevention and control and gaps in records had not been identified through these audits.” from the report
Activities
needs fixingThere were limited organised activities, and inspectors observed people sleeping in the lounge during the day. The home was recruiting an activity co-ordinator.
“There was not enough staff to engage people in meaningful activities, we observed people sleeping in the lounge through the day.” from the report
- 01How many staff are scheduled on each shift now, including at night, and how do you check that this is enough for people's needs?
- 02What has changed in how you investigate unwitnessed falls and put measures in place to prevent them happening again?
- 03How are medicines reviews, storage, controlled drugs and records checked now?
- 04What action has been taken to improve mask use, cleaning records, social distancing and infection control guidance?
- 05How do your audits now identify problems with risks, staffing, medicines, infection control and care records?
This was a focused inspection of Safe and Well-led, prompted by concerns about falls; the other key questions were not inspected during this visit. This explanation was written from the published report of 7 October 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 2020
Inspected but not rated; the previous Requires Improvement rating remained, although inspectors found improvements in consent, governance and infection control.
This was a targeted inspection on 3, 4 and 5 November 2020. Inspectors checked infection prevention and control, and whether earlier actions about consent and governance had been completed. They looked around the home, observed care, spoke with staff and relatives, and reviewed care, infection control and management records.
Inspectors found enough improvement for the home no longer to be in breach of the earlier rules about consent and good governance. Relatives gave positive feedback and said they felt involved in decisions and kept informed during the COVID-19 pandemic.
Infection control arrangements were generally suitable, but inspectors made recommendations about cleaning schedules, recording staff PPE training and staff taking breaks away from work areas. This was not a full inspection. The ratings were not changed, so the previous overall rating of Requires Improvement remained.
Better management checks
The home had strengthened its audits and improvement planning. Incidents and accidents were reviewed for patterns, and feedback was followed up.
“Systems to assess, monitor and improve the service had been made more robust.” from the report
Consent and legal decisions
Inspectors found evidence of capacity assessments and best-interest decisions. Applications and expiry dates for Deprivation of Liberty Safeguards were monitored.
“Where people lacked capacity and important decisions needed to be made, we saw evidence of capacity assessments and best interest decisions in line with legal requirements.” from the report
Positive family feedback
Relatives said care met individual needs, they were involved in decisions and communication during the pandemic was good.
“We received positive feedback about the service from relatives who said care met individual needs and that they had been communicated with well during the COVID-19 pandemic.” from the report
Infection control arrangements
Inspectors were assured about several infection control measures, including visitor controls, admissions, testing and the infection control policy.
“Overall, we were assured that appropriate infection prevention and control systems were in place to help keep people safe within the limitations of the current building layout.” from the report
Some infection control practices needed strengthening
needs fixingInspectors were only somewhat assured about some infection control areas. They recommended stronger cleaning schedules, evidence of PPE training and breaks away from work areas.
“This included ensuring cleaning schedules are more robust, PPE training for staff is evidenced and to ensure staff take breaks away from their work area.” from the report
Training gaps
minorMost staff training was up to date, but some gaps remained. Management said these would be addressed through staff supervision.
“Whilst most training was up-to-date there were some gaps.” from the report
No registered manager
needs fixingThere was no registered manager at the time of the inspection. An interim manager was in place while a permanent manager was being recruited.
“At the time of the inspection there was not a registered manager in place, which is a legal requirement.” from the report
- 01What has been done to make cleaning schedules more robust, and how is this checked now?
- 02How do you record and monitor staff training in PPE, and have all the identified gaps been closed?
- 03How are staff taking breaks away from their work areas, and how is this managed during busy periods?
- 04Who is currently responsible for the home while a permanent registered manager is being recruited?
- 05When will the next comprehensive inspection or full review take place, given that the previous Requires Improvement ratings were not changed?
This was a targeted inspection of infection control and earlier actions about consent and good governance; it did not assess the full five key questions, so the previous ratings carried over. This explanation was written from the published report of 27 November 2020 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
2 rated inspections over 2 years: the service has held its Requires improvement rating throughout.
- October 2021Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedWell-led: Inspected but not rated
- January 2020Requires improvementSafe: GoodWell-led: Requires improvement
- September 2018
Registered with the Care Quality Commission on 17 September 2018.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Leeds
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 £980 to £1,250 a week. 89 can care for a couple. 11 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“Took his time to learn about me read my care plan and to listen to me. great companionship with lots of laughing.”
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.