CQC report explained · a residential care home
What the CQC found at The Hollies Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks linked to pressure area care and constipation were not managed properly. Some medicines were not given according to prescribing instructions.
- Effective?
- Good
- People's needs were assessed before they moved in, and care was adjusted as needs changed. People received suitable food, drinks and access to health professionals.
- Caring?
- Good
- People were treated with dignity and respect. Staff knew people well, listened to their preferences and supported their independence.
- Responsive?
- Good
- Care plans were personalised and included people's histories, preferences and needs. People had access to activities, visitors and support at the end of life.
- Well-led?
- Requires improvement
- Management oversight had improved, but electronic records and audits did not always give managers a full view of repositioning, constipation, fluid intake and medicines. Some mental capacity records contained conflicting information.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found kind, personalised care, but risks and medicines were not always managed safely.
This was an unannounced follow-up inspection on 14 February 2023. Inspectors spoke with people, relatives and staff, observed care, and reviewed care, medicines, staff and management records.
The home had improved since the last inspection. People and relatives were positive about the care. Staff were described as kind, people had choices, meals met dietary needs, and activities were available.
There were still safety concerns. Some people were not repositioned as planned, constipation risks were not always managed, and some medicines were not given exactly as prescribed. The home's electronic records and checks had not always identified these problems.
The overall rating was Requires Improvement. Safe and Well-led were Requires Improvement, while Effective, Caring and Responsive were Good. The home was no longer Inadequate or in Special Measures.
Positive views
People and relatives gave positive feedback about the home, its staff and its management.
“People and relatives provided positive feedback about the service, the staff and the management.” from the report
Staffing and recruitment
Inspectors found enough staff on duty and safe recruitment checks had been completed. People were supported by regular staff they knew.
“Enough staff were deployed to keep people safe. Staff had been recruited safely to ensure they were suitable to work with people.” from the report
Kind and respectful care
Staff protected people's privacy and dignity and supported them to make choices and remain as independent as possible.
“People were treated with dignity and respect. People's views about how they preferred to receive their care were listened to and respected.” from the report
Personalised support
Care plans gave staff detailed information about people's needs, preferences, interests and life histories.
“These were person centred and contained information about how each person should be supported in all areas of their care and support.” from the report
Activities and relationships
The home had an activities coordinator and offered activities in the home, trips out and opportunities to maintain important relationships.
“The service had employed an activities coordinator. People were supported to do activities in the service and to go into their community to join activities” from the report
Repositioning and skin care
seriousOne person was not repositioned as often as their care plan required. The records confirmed this, increasing the risk of harm to their skin.
“Risks in relation to pressure area care had not always been adequately monitored.” from the report
Constipation risks
seriousConstipation was not always assessed or acted on. Records showed that recommended action had not always been taken, putting people at risk of discomfort and harm.
“Risks in relation to constipation had not always been well managed.” from the report
Medicines
seriousSome medicines were not given exactly as prescribed. Skin patches were not always moved to a different site, which could cause irritation and discomfort.
“Some medicines were not given as per prescribed instructions.” from the report
Management records
needs fixingThe new electronic care system did not alert staff or managers when some important care had not happened. Some mental capacity assessments also contained conflicting information.
“The management team did not have full oversight of people's care.” from the report
- 01How do you now make sure people are repositioned at the times set out in their care plans?
- 02How do you monitor bowel movements and make sure laxatives or medical advice are provided when required?
- 03What changes have you made to ensure every medicine, including skin patches, is given exactly as prescribed?
- 04How does the electronic care system now alert managers about missed repositioning, constipation or low fluid intake?
- 05How are you checking that mental capacity assessments are accurate and contain no conflicting information?
This was an unannounced follow-up inspection covering all five key questions, including infection prevention and control, after the previous Inadequate inspection. This explanation was written from the published report of 18 April 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, November 2022
Rated Inadequate and still in special measures; inspectors found serious safety and management failures despite some improvements.
This was an unannounced, focused inspection on 13 and 16 June 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines, staff records and management records.
People and relatives generally described the care and staff positively. However, inspectors found serious concerns about safety. Risks from falls, fire, hot surfaces, water temperatures, moving and handling, and people leaving the home were not always properly assessed or managed. There were not enough staff at night, although staffing was increased after the fire service raised this concern.
Medicines management and staff recruitment had improved. Food, drink and access to healthcare had also improved. However, care records, mental capacity assessments, people's needs assessments and management checks were still not reliable enough.
The overall rating stayed Inadequate. Safe and well-led were Inadequate, while effective improved from Inadequate to Requires Improvement. The home remained in special measures.
Positive views from people
People and relatives generally said staff were kind and supportive. People said they felt safe and could use their call bells for help.
“People and relatives provided positive feedback about the service, the staff and the management.” from the report
Safeguarding improved
The home had improved its safeguarding arrangements. Concerns were reported appropriately and staff understood how to raise concerns.
“At this inspection, the management team had appropriately raised safeguarding concerns when they had occurred.” from the report
Safer recruitment
The home improved its recruitment checks. Staff files showed employment history checks, criminal record checks and references.
“Staff were recruited safely. Disclosure and Barring Service (DBS) criminal record checks were completed as well as reference checks.” from the report
Medicines improved
Most medicines records were complete and medicines were mostly given as prescribed. Medicines were stored securely and staff competency checks had been completed.
“Medicines administration records (MAR) were mostly complete. Medicines had mostly been given as prescribed.” from the report
Nutrition and healthcare
Food and fluids met people's assessed needs, and people were offered drinks regularly. People were supported to see healthcare professionals when needed.
“At this inspection, improvements had been made. Food and fluid met people's assessed needs, no one required a pureed diet.” from the report
Risks of avoidable harm
seriousThe home did not consistently assess or manage risks. Inspectors found that action after falls was delayed and that important health and safety risks remained.
“Not enough improvement had been made at this inspection and the provider was still in breach of regulation 12 in relation to risk management.” from the report
Night staffing
seriousThere were not enough staff at night to keep people safe and support evacuation. Staffing was increased after the fire service attended.
“The provider was advised to increase the number of staff immediately, this was done.” from the report
Incomplete care records
needs fixingRecords did not always show that people received the care they needed. Problems included oral care, catheter care, personal care, bowel movements and incorrect dates.
“Registered persons had failed to operate a robust quality assurance process to continually understand the quality of the service and ensure any shortfalls were addressed.” from the report
Medicines recording
needs fixingSome prescribed supplements and weekly medicines were not recorded or given on the instructed day. Creams, lotions and eyedrops were not dated when opened.
“However, there were some areas for improvement in relation to recording prescribed meal supplements and administration of medicines that were prescribed to be taken once a week.” from the report
- 01What changes have been made to prevent falls, and how are falls now reviewed and followed up?
- 02How many staff are now on duty at night, and how have you checked that this is enough for people's evacuation needs?
- 03What has been done to make fire doors, hazardous rooms, hot surfaces and window restrictors safe?
- 04How do you make sure mental capacity assessments are specific to each decision and that best-interest decisions are recorded?
- 05What checks now confirm that care records are complete and accurate, including oral care, catheter care, bathing, bowel movements and fluids?
This was a focused inspection of Safe, Effective and Well-led only; the Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 8 November 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.
Every inspection of The Hollies Residential Home
5 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at The Hollies Residential Home →
- November 2022Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementWell-led: Inadequate
Read what inspectors found at The Hollies Residential Home →
- March 2022InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2021Inspected but not ratedSafe: Inspected but not rated
- August 2019Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014Inspected but not rated
- November 2020
Registered with the Care Quality Commission on 2 November 2020.
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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