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Inspection Summary

Overall summary & rating


Updated 22 April 2020

About the service

Holly Tree Lodge is a residential care home providing personal care to 10 people with learning disabilities at the time of the inspection. The care home is registered to accommodate up to 14 people, however, the home is no longer able to provide accommodation for more than 10 people. The building was spread across a main house and three additional and separate bungalows.

The service had not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service did not receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was registered for the support of up to 14 people. This is larger than current best practice guidance. The size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras or anything else outside to indicate it was a care home.

People’s experience of using this service and what we found

People and relatives told us they felt safe. However, we found that systems and practices in the service meant people were not safe and at risk of harm and abuse. Risks to people had not always been identified and assessed.

Cleanliness in the communal areas of the home was not to acceptable standards which meant people were at risk of infection or disease or other illnesses. Medicines were not secure due to the keys being openly available to anyone and one person’s supply of emergency medicine had run out.

Staff recruitment process had not been completed as required which meant that staff were not suitably assessed to ensure they were safe to work with vulnerable people. Staff rotas were not well managed which meant staff were working excessively long hours and shift patterns that meant people were at risk or errors or harm due to staff not being fully rested.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People were not always consulted about their consent before support was given and mental capacity assessments were not always completed or were not decision specific. This meant people’s rights were not supported and protected.

The service did not apply the principles and values of Registering the Right Support and other best practice guidance. People were not encouraged to do things for themselves or be involved in daily tasks.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons, there was a lack of choice and control, limited independence, limited inclusion e.g. People did not have the opportunity for meaningful activities and staff did not promote their interests, social network, hobbies and cultural or religious needs.

People were not valued of respected as they were living in unclean environment which was also in need of repair and redecoration in many areas. Staff did not always talk with people when carrying out tasks and choices were not offered.

People were supported to access a variety of health and social professionals when required and actions suggested by professionals were put into place. Staff did ensure that people who were supported in bed due to their conditions were well cared for in relation to skin and pressure care. Records showed people were involved in reviews along with their relatives and social car

Inspection areas



Updated 22 April 2020

The service was not safe.

Details are in our safe findings below.



Updated 22 April 2020

The service was not effective.

Details are in our effective findings below.



Updated 22 April 2020

The service was not caring.

Details are in our caring findings below.



Updated 22 April 2020

The service was not responsive.

Details are in our responsive findings below.



Updated 22 April 2020

The service was not well-led.

Details are in our well-Led findings below.