Archived: The Hollies

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 our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the safe care and treatment of people.

This service scored 44 (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 did not always have a proactive and positive culture of safety, based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Improvements were needed to develop a learning culture. The registered manager told us they had received a visit from the local authority during 2026, and feedback had identified areas in need of improvements. During our visit we found these had not always been acted on. For example, the registered manager had been asked to ensure volunteer staff had checks undertaken to ensure they were of suitable character to work at the home. For example, a criminal record check; known as a DBS (Disclosure and Barring Service), but we found no action had been taken by the registered manager to apply for these. We have further reported on this in our safe staffing quality statement in this section of the report.

There were no robust systems in place to record accidents and incidents. This meant that should any such incidents occur, with no recording system in place, it may be more difficult to review details and take actions to reduce risks of reoccurrence.

The registered manager and volunteer manager felt they had learned some lessons from their 2025 environmental health inspection. The volunteer manager told us, “We had the kitchen inspection and were given a list of things to improve on. We did these and the inspector came back and we got 4 stars (out of a possible 5 stars).”

The provider worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager and volunteer manager gave us examples of how they worked with healthcare professionals. For example, 1 person had an annual health scan, and this had revealed a need for further investigation and the managers were supporting this person to access a specialist NHS consultant.

Both managers gave us examples of how they supported people to attend GP and dental appointments when needed.

People did not have ‘hospital passports,’ or any alternative way to ensure important information was easily available. Improvement was needed to develop these to ensure safe systems, pathways and transitions could take place between services. A hospital passport is a document containing personal information that helps healthcare professionals understand a person’s unique health needs, communication preferences and personal preferences to ensure they receive personalised care.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always have the means to share concerns quickly and appropriately.

People felt safe living at the home. One person told us, “I am safe here, I like it.” However, some improvements were needed. Whilst the registered manager understood it was important to protect people from the risks of abuse; they had not acknowledged the importance of undertaking checks on their volunteer staff to ensure suitability of character to work with people.

The registered manager and volunteer staff had not completed training on safeguarding people and there was no policy in place for staff to refer to if needed. However, the volunteer manager told us, “I have never had any concerns about the care here and if I did, I could report it to the CQC.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the registered manager was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. Where the risks to 1 person had been deemed sufficient that restrictions needed to be in place for their safety and wellbeing, an appropriate authorisation had been sought and was in place.

The registered manager was not fully aware of their legal duties in reporting any specific incidents, such as serious injuries, to us and the local authority as required and did not always have the means available to them to report, if needed, in a timely way. For example, the registered manager and volunteer manager told us they were not familiar with the CQC provider portal and did not have access to this. We signposted them to support to enable access; which would be needed as a means of reporting any concerns to us. During our visit we found no evidence of incidents that should have been reported to us.

The provider did not always work with people to understand and manage risks by thinking holistically. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some risks of potential harm to people had been identified and risk management plans were in place. For example, 1 person had an identified risk related to their lack of road safety skills. The person’s management plan was for them to always be accompanied when out in the community.

The volunteer manager described 1 person as having a risk of choking if they ate too quickly and strategies were in place to ensure this person was encouraged to eat slowly and always have ‘bite size’ pieces of food. We suggested the registered manager request that this person’s GP refer them to the speech and language team (SALT) for any additional advice and guidance, which they said they would do.

The registered manager and volunteer manager knew people very well and felt they could manage potential day-to-day risks of harm. However, risk management plans needed further development to ensure all potential risks of harm were assessed and had management strategies in place. For example, 1 person wore pyjamas during the daytime, and the volunteer manager explained this person became anxious if they dressed in daytime clothing if they were staying at home as they associated daytime clothing with going out in the community. We found no information related to this person’s triggers for anxiety in their plan of care. Another person was described as having some early changes in their mobility and whilst they continued to manage the stairs in the home, there was no risk management plan in place for this.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

During our visit, we identified multiple areas of concern related to fire safety measures in the home. Our concerns included risks of fire outbreak in the home, the risk of serious harm to people in the event of a fire, the lack of planning, by the registered manager, of how to safely evacuate the home in the event of an emergency. For example, the room housing the tumble-dryer was full of combustible materials and the volunteer manager told us clothing was stored in the room on hanging rails and boxes. There was no fire or smoke detection system in this room and a door leading to the rest of the home was left open. Other doors in the home did not close into the recess well, which meant they would not give protection against smoke or fire spreading in the home.

Two days after our inspection visit, we received a photograph showing us this room had been cleared of all combustible items, and a smoke detector had been fitted.

The registered manager’s fire assessment had not been reviewed since 2018. The assessment referred to the use of ‘escape ladders,’ and the registered manager told us these could be hung from first floor windows. The registered manager added they would “be reluctant to use them as they were very narrow.” There was no evidence that people living at the home had been assessed as capable of using such escape ladders.

No one living at the home had a personal emergency evacuation plan (PEEPs) in place and there was no available layout of the home to hand to a fire officer in the event of an emergency. The registered manager and volunteer manager told us fire drills and fire scenarios had not taken place, which meant staff and people may not know what to do in the event of an emergency.

Following our inspection visit, we made a referral to the local fire service and shared our concerns for them to follow up on with the registered manager.

The registered manager told us they had recently had a new gas boiler fitted, but they were unable to share any gas safety, electrical safety or legionella test certificates with us. The registered manager told us, “I don’t have those and we don’t do legionella testing.” The volunteer manager said, “It might be worth us contacting the owner of the building and seeing if they have them and setting up a file for certificates. If they don’t we will have to get them done.” The purpose of legionella testing through water sampling is to protect against people contracting legionaires’ disease. The purpose of utility safety certification is to ensure services, such as gas and electrical items, remain safe.

The home had large sash-type windows and during our visit these were open. On the first floor, windows had no restrictor in place to reduce the level of opening. There was nothing to suggest people would climb or fall out, but the restrictor is a measure to prevent such risks of harm occurring.

Collectively, these concerns demonstrated a significant lack of oversight of fire safety arrangements. The registered manager could not provide assurance that people could be safely evacuated in the event of a fire, and systems intended to identify and mitigate fire risks had not been effective. This increased the risk of avoidable harm to people living at the service.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider could not demonstrate that people providing support had the competency, skills or suitability required to safely meet people's needs. The service relied heavily on the experience of the registered manager without effective systems to assure the quality or safety of support provided by volunteers.

The registered manager told us they did not ever employ staff or use any agency staff. They told us they supported people and met their needs themselves with some support from volunteer staff, such as the volunteer manager who offered 10 hours a week at the home.

The registered manager used friends and family members as the volunteers and had not felt it necessary to do any pre-volunteer staff checks. We found no application form to volunteer at the home had been completed, no references undertaken and no DBS check had been undertaken.

During our visit we requested DBS checks be requested and evidence of this was sent to us the following day.

The registered manager had not completed an assessment of each person’s needs to determine if, overall, 1 staff member was sufficient. During our visit, we did not find people’s needs were unmet. The registered manager lived at the home and slept during the nighttime. There were no systems in place for people to alert the registered manager if they needed support or help during the night.

The registered manager and volunteer manager told us they had not completed any training. The volunteer manager told us, “A few months ago, a person’s social worker visited and suggested we contact an organisation to gain support with training, but we haven’t done so yet.”

Improvements were needed in training, development opportunities and the supervision of volunteer staff. None of the volunteer staff had completed any training such as safeguarding adults from abuse, the safe handling of medicines or learning disability training. The registered manager had not assessed anyone’s knowledge or skills to assure themselves volunteer staff had the skills they needed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Some improvements were needed to prevent the risks of cross infection. For example, in a shared bathroom, 1 person’s toothbrush was lying behind the taps on the sink unit. Splashes from hand-washing posed potential risks of cross infection.

Lino fitted in the shared bathroom was not fully sealed at the doorway and debris had built up. The lack of a seal meant effective cleaning was difficult to achieve.

People’s bedrooms were very clean and tidy, and communal areas were homely offering a relaxed setting. However, some communal areas had become dusty and cobwebs had gathered. A bin in the ground floor toilet room was full. The registered manager told us, “A friend comes twice a week, volunteers and cleans for me.” Due to the size of the home, we found this arrangement did not currently ensure the whole homes’ cleanliness was maintained.

Training in infection prevention and control had not been completed; however, both the registered manager and volunteer manager understood the importance of using personal protective equipment (PPE) which they told us was available for use when needed. We saw paper-towels and foot pedal operated bins were in place to reduce risks of cross infection.

The provider did not ensure all aspects of medicines management were robust.

Whilst we found no evidence that people were not receiving their medicines as prescribed and people’s Medication Administration Records (MARs) reflected this, improvements were needed in some areas. The registered manager told us it was usually themselves who administered medicines to people on a daily basis. However, on occasions volunteer staff administered medicines to people, for example the registered manager’s relative had taken 2 people on holiday and administered medicines to them.

The registered manager and volunteer staff had not completed any training in the safe handling of medicines, nor had any competency assessment to ensure their skills were sufficient. There was no medication policy in place for the registered manager or volunteer staff to refer to when needed. This increased the risk of potential errors in the handling of medicines.

During our visit we looked at people’s medicines stored in a secure cabinet. We found 1 person had an out-of-date pack of prescribed medicine alongside a pack of the same medicine that was in-date. We could not be assured which pack was being used and requested the out-of-date be disposed of safely.

The registered manager had also secondarily dispensed 2 people’s medicines into ‘dosett boxes’ from pharmacy labelled boxes which they had then disposed of. The dosett boxes were not named and there was no safe means of determining which tablet was which. The registered manager told they did this for “ease of them giving people their medicines each day.”This was not in line with safe and best practice.