CQC report explained · a residential care home
What the CQC found at The Hollies
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from avoidable harm, medicines were given safely, staffing levels were sufficient and infection control was managed well. Some individual risks were not fully documented, but the manager acted on this.
- Effective?
- Good
- People's needs were assessed before admission and care plans were updated. Staff had induction, training and supervision, and people were supported with food, drink, healthcare and legal consent.
- Caring?
- Good
- This question was not looked at during this focused inspection.
- Responsive?
- Good
- This question was not looked at during this focused inspection.
- Well-led?
- Good
- Managers had introduced audits and checks and acted on concerns identified during the inspection. However, audits had not detected gaps in records about some individual risks.
What inspectors found, December 2020
Rated Good; inspectors found safe, kind care and major improvements, but some individual risk records were incomplete.
This was a focused inspection carried out over four visits in November 2020. Inspectors spoke with people, relatives, staff and managers. They observed care and checked care, medicine, staff recruitment, training and management records.
People appeared happy and comfortable. Staff were friendly and respectful. Inspectors found enough staff, safe medicines systems, good infection control, suitable training and support, and regular access to health professionals. Food and drink were provided in line with people's needs and preferences.
Some risks, including aspiration, diabetes, challenging behaviour and COVID-19, had not been fully assessed and recorded. Some medicine records also needed correction. The manager acted on these issues during or shortly after the inspection. The home was rated Good overall, with Safe, Effective and Well-led rated Good.
Kind relationships
People appeared happy and had friendly, positive relationships with staff. Inspectors saw laughter, conversation and respectful support.
“People were observed to be happy and content.” from the report
Improvement since last inspection
The home had addressed the earlier problems with risk management, medicines, recruitment, training and governance. It was no longer in breach of regulations.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Infection control
The home had increased cleaning, provided suitable protective equipment and given staff more infection control training during the COVID-19 pandemic.
“At this inspection we found that the home was managing infection prevention and control well especially during the COVID-19 pandemic.” from the report
Staffing and training
Inspectors found enough staff to support people safely. Staff had induction, ongoing training and supervision, including agency staff.
“Throughout the inspection, we observed there to be sufficient care staff available to support people safely with their needs.” from the report
Communication with relatives
Relatives said communication had remained good during the pandemic, through calls, emails and newsletters.
“Relatives confirmed that throughout the pandemic the communication between them and the home had been good and that they were regularly kept updated about their family member.” from the report
Some risks were not fully recorded
needs fixingSome risks linked to behaviour, COVID-19, aspiration, diabetes and other health conditions had not been formally assessed and documented. The manager updated the five care plans inspected and said the remaining plans would be reviewed.
“certain individualised risks had not been formally assessed and documented.” from the report
Medicine record checks
needs fixingHandwritten medicine record entries had not been signed by two people to confirm them. The manager agreed to correct this immediately.
“where handwritten entries had been made on the MAR, these had not been signed by two people to verify and confirm the entry has correct.” from the report
One missing agreement for hidden medicine
needs fixingFor one person receiving medicine hidden in food or drink, the pharmacist had not signed the agreement. Inspectors asked the manager to obtain the required agreement.
“However, for one person, the pharmacist had not signed the agreement for covert administration.” from the report
- 01How have you checked that every person's risks, including aspiration, diabetes, challenging behaviour and COVID-19 risks, are fully recorded?
- 02What checks are now in place to make sure handwritten medicine record entries are signed and verified correctly?
- 03Has the missing pharmacist agreement for covert medicine administration been obtained and reviewed?
- 04What were the previous ratings for Caring and Responsive, which were not assessed during this inspection?
- 05How do you monitor whether audits are finding gaps in care plans and risk records?
This was a focused inspection of Safe, Effective and Well-led, with infection control also checked; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 18 December 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.
What inspectors found, March 2019
The Hollies was rated Requires Improvement; inspectors found kind, person-centred care but serious gaps in safety records, infection control, recruitment and oversight.
This was an unannounced inspection on 4 December 2018. It followed a complaint and took place during the night shift. Inspectors spoke with people, relatives, staff and a healthcare professional. They observed care, meals, handover and medicines rounds, and checked care plans, medicines, staff files and other records.
Inspectors found that some care records were completed before care happened. Other required checks, repositioning and fluid records were missing. They also found poor infection control, missing window restrictors and gaps in staff recruitment checks. Medicines were generally given safely, but some medicines systems needed improvement.
People and relatives were positive about the kindness of staff. Care plans were personalised, people's health and food needs were supported, and people were involved in choices. However, checks by the provider and manager had not identified important problems. The overall rating was Requires Improvement, with Caring and Responsive rated Good.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors saw staff respecting privacy and dignity and encouraging people to remain independent.
“People and their relatives were happy with staff at the home.” from the report
Personalised care
Care plans included people's histories, needs, wishes and everyday preferences. Staff knew how people wanted to be supported.
“People's care plans contained comprehensive information about their needs and wishes so that staff could understand how they wanted to be supported in the home.” from the report
Food and health support
People had food choices and support with eating and drinking. Staff also worked with healthcare professionals to support changing health needs.
“People received support with eating a balanced diet and had enough to eat and drink.” from the report
Choice and involvement
People could choose when to get up and go to bed, where to spend their time and what they wanted to eat. Their consent and least restrictive care were considered.
“People had choice over their food and when they wanted to get up and go to bed.” from the report
Infection control and environmental safety
seriousThere were no clinical waste bins inside the home, and soiled pads were put in an open bag on the floor. Window restrictors were also missing during the inspection, although these were fitted afterwards.
“We saw staff put soiled pads in an open bag on the floor which was not hygienic.” from the report
Staff recruitment checks
seriousSome staff files did not contain full employment histories or suitable references. The home also did not have confirmation of checks for agency staff providing one-to-one care.
“There was a lack of employment history and social care related references in the staff files we inspected.” from the report
Medicines procedures
needs fixingA tablet cutter was dirty and there was no written guidance for giving one person's as-needed sedative medicine. The home agreed to replace the cutter and add guidance.
“There was no written protocol for when to give 'as and when required' sedative medicine to one person.” from the report
Activities did not always happen
minorOn the inspection day, the planned activity did not take place and staff did not arrange alternatives. Most people spent the day watching television or sitting in an armchair.
“On the day of the inspection there was a lack of stimulation for most people.” from the report
- 01How do you now make sure care records are completed when care is actually provided, including repositioning, hourly checks and fluid intake?
- 02What changes have been made to clinical waste arrangements and other infection control practices?
- 03Have full employment histories, references and required checks now been completed for all staff and agency workers?
- 04What written guidance is now in place for as-needed sedative medicines, and how are medicine audits carried out?
- 05How do you make sure planned activities happen, or that suitable alternatives are provided?
This was an unannounced inspection covering all five CQC questions, following a complaint and including observations of night and day care, meals and medicines. This explanation was written from the published report of 9 March 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 The Hollies
3 rated inspections over 4 years: the service has held its Good rating throughout.
- December 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016
Registered with the Care Quality Commission on 19 July 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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