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.
What inspectors found, June 2023
The Hollies is rated Good; inspectors found safe, caring support and better management, but medicines checks still need improvement.
This was an unannounced focused inspection on 15 May 2023. One inspector spoke with people, relatives, staff and a health professional. They observed people during lunch and checked care records, medicines records, recruitment files and management systems.
The home was rated Good for Safe and Well-led. People said they felt safe and were happy with their care. Inspectors found enough staff, suitable safeguarding arrangements, detailed care plans and risk assessments, and improvements in reporting accidents and incidents.
The home had improved since the previous inspection in September 2021, when it was rated Requires Improvement. Medicines records were more secure and complete, and earlier concerns about care plans, risk records and notifications to CQC had been resolved. However, inspectors made two recommendations about medicines protocols, handwritten records and staff competency checks.
Effective, Caring and Responsive were not inspected during this visit. Their previous ratings were used when calculating the overall Good rating.
People felt safe
People and relatives said people were safe. Inspectors observed people who appeared relaxed, happy and comfortable with staff.
“People told us they were happy with the care they received, and people said they felt safe living there.” from the report
Enough staff
Inspectors found sufficient staff to meet people's needs. Staff had time to provide personal support and social interaction.
“There were sufficient numbers of staff employed and on duty to meet people's assessed needs.” from the report
Individual care planning
Care plans and risk assessments were detailed, up to date and tailored to people's needs, preferences and communication.
“Records of people's care were individualised and reflected each person's needs and preferences.” from the report
Improved management
The home had improved its management systems since the previous inspection. Managers carried out audits, understood their responsibilities and acted on incidents and feedback.
“The management and staff worked to drive improvements across the service.” from the report
Respectful support
Staff knew people well and were observed speaking with them in a dignified and respectful way. Staff gained consent before providing support.
“Staff were observed talking to people in dignified and respectful way.” from the report
Medicines given when needed
needs fixingForms existed for medicines prescribed when needed, but they had not been completed with guidance for staff. Inspectors recommended completing all these protocols.
“Protocols forms were in place however, these had not been completed to provide guidance to help staff make consistent decisions.” from the report
Medicines competency checks
needs fixingAll staff had completed medicines training, but the home had not completed checks of their practical competency. Some handwritten medicines entries were also not signed or dated.
“At this inspection we found all staff had completed medicines training, but no competency checks had been completed.” from the report
Fire doors
needs fixingThe fire service had told the home that all internal fire doors needed replacing. Replacement work had started at the time of inspection.
“The provider had already started to replace the fire doors.” from the report
- 01Have all medicines protocols for medicines given when needed now been completed?
- 02Have competency checks been completed for every staff member who administers medicines?
- 03Are all handwritten medicines record entries now signed and dated?
- 04Have all the internal fire doors been replaced, and has the work been checked as complete?
- 05What were the previous ratings for Effective, Caring and Responsive, which were not inspected during this visit?
This was a focused inspection of Safe and Well-led only; the other three question ratings were carried over from the previous inspection. This explanation was written from the published report of 28 June 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 2021
The Hollies rated Requires Improvement; inspectors found kind care and enough staff, but medicines and management systems still needed improvement.
This was an unannounced focused inspection on 23 September 2021. Inspectors looked mainly at Safe, Effective and Well-led because of concerns about staffing, medicines, the environment and care quality. They spoke with people, staff, relatives and a health professional, observed care, and checked care, medicines, recruitment and management records.
The home was rated Requires Improvement overall. Safe and Well-led were also Requires Improvement. Effective was rated Good. Inspectors found enough staff, kind and respectful care, good staff training, suitable support with food and drink, and infection control measures. People said they felt safe and relatives were confident in the care.
There were still three legal breaches. Medicines records and guidance were not reliable enough, some required incidents had not been reported to CQC, and management checks and records were not effective. Inspectors found no evidence that people had been harmed from these concerns, but said further improvement was needed.
Kind and respectful care
People consistently said they felt safe and staff were caring and respectful. Inspectors observed many kind interactions and staff spending time talking with people.
“We observed many kind and caring interactions between staff and people.” from the report
Enough staff
Inspectors found enough staff to meet people's assessed needs. Call bells were answered promptly and people said they did not have to wait long for help.
“There were enough staff to meet people's needs and ensure their safety.” from the report
Staff training
Staff said they had the training and support needed for their roles. Training was tracked and updated across a wide range of subjects.
“The training matrix tracked staff training, and this had ensured all staff received the training and updates needed to provide safe consistent care.” from the report
Medicines systems
seriousMedicines records did not always include enough information, there was no clear guidance for some medicines, and staff competency checks were not taking place. A new system had started after the inspection but was not yet fully implemented.
“We judged this was a continuing breach of Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Incidents not reported
seriousThe registered manager had not told CQC about two incidents that should have been reported. The home also had limited systems for recording, investigating and learning from incidents.
“The registered manager had not informed CQC of two notifiable incidents in line with the regulations.” from the report
Confidentiality of medicines records
needs fixingMedicines administration records were kept in a communal area where other people might have accessed them. This did not protect people's privacy.
“Medicines administration records were not stored securely in a way that maintained people's privacy.” from the report
- 01What changes have been made to the medicines system introduced after the inspection, and how are you checking that it is working?
- 02How do you now record guidance for medicines given when required and check staff competency in administering medicines?
- 03What formal staff roster is now used to show who is on duty and whether staffing levels and skills are suitable each day?
- 04How do you record, investigate and learn from falls, medicine errors and other incidents, and when are they reported to CQC?
- 05Where are medicines administration records now kept, and how do you protect people's privacy?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and their previous ratings were used in the overall rating. This explanation was written from the published report of 2 November 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
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- June 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2020Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- March 2019
Registered with the Care Quality Commission on 5 March 2019.
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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