Holly House

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.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The provider had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Records demonstrated incidents and accidents were being dealt with and there was evidence of lessons learned taking place. Detailed records of events and how these were dealt with were completed and shared with the staff team in meetings and practice workshops. The nominated individual and management team had a good understanding of events and how they shared information and updates with the staff team and involved relevant professionals to keep people safe. We discussed 1 person and how they planned to engage and support them with staff that promoted their likes and choices in their day to day lives.

Staff knew the process to report and act on incidents. One said, “Incidents are reported immediately, recorded, and reviewed by management with actions put in place.” One staff member told us they were confident any concerns relating to safety would be addressed. However other staff discussed a recent increase in incidents for 1 person which they felt this was due to staffing allocation for them. Relatives raised no concerns about their family members safety.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care.

Relatives confirmed assessments had taken place prior to people moving into the service and the transition process was, “As it should be.” Care records included information about the involvement of professionals in supporting people’s individual needs. Detailed hospital passports had been developed to support a safe transfer if an admission to hospital was required.

Detailed assessments were undertaken to support transitions for people moving in and staff confirmed information about people was recorded in their care records. One told us, “When new people come into the home, [staff member] aided with their transition and support plan. All staff then read the support plan, so they are aware of person likes and dislikes, needs and medical conditions. Senior staff explain to staff how to care for a person.”

Professionals we spoke with talked about how they were involved in assessments and ongoing reviews of people. One talked about the positive working relationship between them and the service. However, others discussed difficulties in relation to transitions for 1 person and ensuring their needs could be met safely. The provider told us how they supported this person and their individual needs and their plans going forward.

Staff were able to discuss how new people were admitted to the service to support a safe transfer. They told us, “We have had no new admissions recently, when new people come into the home, staff member aided with the transition and support plan. All staff then read the support plan, so they are aware of persons likes or dislikes, needs, medical conditions. Senior staff explain to staff how to care for a person” and, “We are informed via handovers (of admissions), management communication, and care plan updates before admission.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

None of the people or relatives we spoke to told us about any safeguarding concerns. People said they were, ‘Happy’ in the service. A relative said there was, “Nothing worrying me at all.” Staff and management had a good understanding of what to do if abuse was suspected. They told us, “I would report immediately to the (registered) manager or safeguarding lead, document the concerns, and escalate if necessary” and, “If I suspected abuse I would report to the manager. If they were not doing anything about it I would go to the police and or the local authority.” However, a staff member was unable to discuss an incident that had occurred recently in the service. We discussed this with the management team who explained the reason for this was due to leave. There was an up to date safeguarding policy and staff told us, and the training matrix confirmed they had undertaken relevant training.

Detailed systems were in place to investigate and act on allegations of abuse. Records included logs of events and detailed information of investigations, actions taken and lessons learned, including plans to reduce risks following events. Information about safeguarding concerns were discussed in monthly staff meetings and managers meetings about people.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

A range of individual risk assessments had been developed to support people’s needs safely. There was evidence that these had been reviewed as needed. Relatives told us the service had assessed their family members risks, and measures were in place to reduce any risks. Staff confirmed they had access to assessments to support them in managing people’s needs and reduce the risks. One said, “Care plans and risk assessments clearly outline risks for example; choking and falls, with guidance on how to manage them.” Some professionals discussed the complex needs of some people living in the service and the importance of ensuring staff accessed and followed assessments according to people’s needs. The provider told us they were working with professionals very regularly to ensure all people were safe and receiving high quality care.

Environmental risks in a number of areas had been assessed. These were detailed and covered relevant areas. Fire risk assessments had been undertaken; the provider confirmed all required actions had been completed. told us they would ensure this was reflected in the assessments. The environment had been adapted to consider the complex and individual needs of people. Refurbishment work was ongoing to make improvements where areas required.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had thoroughly considered the environment people were living in. Adaptations had been undertaken to a very high standard, including ensuring people’s personal space supported them to live the life they chose safely. People’s personal space was individualised and they told us they had been involved in how they liked their rooms. Work was ongoing in 1 person’s room to ensure this was safe for them to live in.

All rooms had their own ensuite and, all but 1 room included a lounge and kitchenette area, and 1 person’s accommodation was a self-contained separate annex. The environment helped to support people in achieving daily living tasks and promoting their independence. Two of the 3 bedroom rooms had their own enclosed garden space and there was a large communal secure garden for all people to access.

Servicing, audits and checks on a range of areas and equipment had been completed and were up to date. The provider discussed that the management team had undertaken specific training to ensure checks and logs were completed in a robust manner and that the maintenance manager supported them with this process. Information and emergency equipment to support people and staff in the event of an emergency was available. Personal emergency evacuation plans were in place and included information about people’s individual needs and how to support them safely in the event of a fire.

No concerns in relation to the environment were raised by people or relatives. People said they liked their home and were happy. A relative told us their family member was proud that they had been involved in the decoration of their room. Staff were positive about the environment and safety. One said, “Very safe environment.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were recruited safely. Records confirmed relevant recruitment checks had been undertaken. The management team told us they were over recruited to ensure gaps in shifts were covered. We discussed that a matching tool was used to ensure they recruited staff appropriate for the tasks they were required for and they were looking at how to involve people in the recruitment process. Staff files confirmed, and staff told us supervision and observed competency checks were undertaken. Comments included, “Training is good we have face to face and yearly refreshers. Supervisions are every month; we have wellbeing supervisions and every quarter we have performance review supervisions.”

Staff told us they had undertaken training and records confirmed a wide range of topics had been completed by the staff team. This would support them in the delivery of care to people. Comments included, “Enough staff, fantastic training, I enjoy all the training, it is all face to face. Very target audience based” and, “Staffing levels are OK now. The training is good here, I have done loads of courses, medicines, safeguarding. Online courses and face to face.” However, a staff member discussed that duty rotas and staff allocation needed to be considered to support people’s individual needs.

People and relatives raised no concerns about the staff and their skills, but they would benefit from staff who were able to support them to visit family. One said, “There’s always someone with [person], on call and in charge. The only problem, is being able to see [person] and family time.” Some people fedback that they had found it difficult to adapt to the changes in the management staff recently. And a representative discussed their, ‘frustrations about the staff turnover and the importance of ensuring a consistent staff team for [person].’

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

No concerns in relation to infection control were raised. The service was clean and tidy, and staff had access to PPE (Personal Protective Equipment) as needed. Dedicated housekeeping staff were available and cleaning was ongoing. Records had been completed to confirm regular cleaning and audits were taking place. Up to date policy and guidance was available. Staff told us, “(The service is) clean and tidy, housekeeper Monday to Friday and night staff clean every night, care staff clean at weekends. It is very clean here. Some people get involved in cleaning after cooking for example.” We discussed with the management about the importance of staff removing outdoor clothing during day to day activities.

No concerns were raised by people or relatives about cleanliness in the service. One relative told us, “Yes, very, very happy (it is clean and tidy), I don’t think outbreaks happen.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were being managed safely, information policy and guidance was in place, and staff had undertaken training and competency checks. Information about the staff understanding of STOMP (stopping the over medication of people with a learning disability, autism, or both) was provided. Staff told us, “Medicine competencies are yearly. If we make an error we complete a competency and refresher course. If I needed to give PRN medicines I would have to ask a senior. There are always 2 people involved to make this decision. We log the techniques tried before administration, follow up an hour later, to see if the medicine was effective.”

Medicines records were completed electronically and in full. We discussed with the senior team their plans to ensure as required records for medicines contained detailed information to support their administration. We observed mostly the safe administration of medicines; we discussed our observations of an administration requiring 2 people to check and the importance of ensuring this is completed in line with guidance. Medicines were stored safely and the management team discussed the introduction of more detailed checks and guidance to support staff with temperature checks and what to do if they were out of range. No concerns in relation to the medicines administration was raised by people or relatives. One said, “[Person] is aware of medicines and they tell me.” We discussed with the provider how they ensured all staff knew the medicines that people took.