Holly House Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At the last inspection we rated this key question good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider and registered manager had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. The management team demonstrated an outstanding culture of learning and continuous improvement. For example, the routine infection prevention team audit had scored the service has being nearly fully compliant in all aspects but consistent completion of hand hygiene audits. The registered manager shared this finding with not only the team but within their newsletter as well as what action they were taking to rectify this issue. Everyone took this on board and the next infection control team’s audit scored them at 100%. On another occasion the registered manager had identified staff needed a greater understanding of the risks associated with a change in a person’s health. To address this they had a multi-disciplinary team meeting to explore all aspects of the person’s needs and what staff needed to do in each situation. The outcome was communicated between teams and across departments so all could work effectively with the person. Professionals praised the team’s knowledge and responsiveness.

The management team also constantly looked to see where lessons could be learnt and make improvements. The changes to the way they monitored services meant they could readily identify even minor changes in practice and use the information to complete deep dives into the service. This had led to a wide range of improvements, including introducing new technology to assist staff to actively support people with their hydration and falls risk management. Staff were encouraged to share lessons from incidents and near misses, and these were discussed in themed supervision sessions. Learning was cascaded across the service and shared with other locations operated by the provider. Staff described feeling listened to and involved in shaping practice. A staff member said, “I feel I am involved in how well the service works and suggestions for any improvements are listened to, they have been used.”

Systems were in place to ensure safe care pathways and transitions. Risk assessments were comprehensive and regularly reviewed, enabling staff to manage presenting risks effectively. Staff worked collaboratively with healthcare professionals to respond promptly to changes in people’s conditions. Professionals describe Holly House as a service that delivers high‑quality, person‑centred care, underpinned by strong leadership, excellent multidisciplinary team (MDT) working, proactive risk management, and a genuine culture of kindness and respect. A visiting professional said, “They [staff] consistently implement advice, request clarification where needed, and communicate openly about residents’ progress. This collaborative approach enables residents to maximise their functional independence and overall quality of life.”

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. When incidents occurred staff completed a full investigation and took a proportionate, balanced approach when dealing with them. Staff had training and a good understanding of what to do to make sure people were protected from harm or abuse. Records showed safeguarding incidents were investigated and lessons learned were shared with the team. Staff understood when Deprivation of Liberty Safeguards (DoLS) authorisations would need to be sought and what to do if there were conditions imposed.

Staff worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments were in place and assisted staff to identify how to mitigate risks. Staff described how they worked in partnership with individuals, using shared decision-making to promote autonomy and positive risk-taking. This approach supported recovery and independence while maintaining safety. People felt confident staff understood them and could support them to manage any risks posed.

The provider detected and controlled potential risks in the care environment. The provider had a rolling programme of refurbishment. People were supported to be as independent as possible within the environment. Environmental risks were assessed and addressed. They made sure equipment, facilities and technology supported the delivery of safe care and worked with external professionals to review people’s aids. The staff team knew who to contact when people might benefit from additional aids or equipment. Staff were trained to use any equipment people needed.

Staff worked together well to provide safe care that met people’s individual needs. The provider ensured enough staff were on duty to meet people’s needs. However, relatives and staff noted occasional pressure points, particularly at mealtimes but we found the management team had recognised this and constantly reviewed staff deployment. One staff member said, “I have undergone face-to-face and e learning training, which has helped me in my role and given me better understanding of life in a care home and what this entails.” People confirmed there were always enough staff on duty.

Recruitment practices were meeting requirements, and the new administrator had reorganised the files to show they clearly met the regulatory requirements. People were actively involved in recruiting staff. The provider promoted a learning culture and ensured staff had access to a wide range of training. Staff had received mandatory and condition specific training. Staff supervision sessions were completed in line with the provider's policy.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff followed infection prevention and control protocols, including appropriate use of personal protective equipment and regular audits. An infection control champion carried out daily checks and liaised with the management. Domestic teams completed frequent touch-point cleaning, and staff received annual IPC training and refreshers. The provider was redesigning laundry facilities to improve separation of clean and dirty areas, supporting better infection control.

Staff made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff who administered medicines had the appropriate training and competency checks. Storage areas were secure, and temperature checks were recorded. Medicine Administration Records (MAR) were accurate, and controlled drugs were handled in line with regulations. Regular audits were regularly completed. If any issues were identified action plans were implemented to address them, and staff were reminded of best practice. These practices ensured staff consistently managed medicines safely.