The Hollies Residential 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 our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 safe care and treatment, we found concerns regarding the management of environmental risks and how medicines were managed.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice. We found similar issues during this assessment relating to the environment which had been highlighted at previous inspections. Whilst the new manager reviewed incidents and accidents, the provider did not have effective oversight. For example, some incidents which had happened prior to the manager starting had not been reported or investigated to ensure lessons were learnt. This meant there was risk incidents would be repeated which increased the risk of harm to people.

The manager worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services. Staff had documentation in how to support people in line with their needs. We found care plans had been updated and people told us they were involved in developing their care and support plans. Staff and the manager communicated well with other professionals. Records evidenced input form health care professionals. For example, we reviewed a care plan of a person who lived with a wound, advice had been sought from the community nursing team and used to develop the persons care plan. The manager acknowledged when people’s needs changed and recognised when the service could no longer support them. The manager ensured people were supported and received assessments prior to moving to alternative services. This meant people transferred safely in between services.

Safeguarding processes in place needed strengthening to ensure people were protected from abuse and neglect. We found whilst the manager had a safeguarding tracker in place to monitor safeguarding incidents, not all incidents were reported to the local authority safeguarding team. For example, we found an incident where a person had missed their prescribed medicines for a number of days, this had not been reported to the CQC or the local authority safeguarding team. This meant there was an increased risk the incident could re-occur. We also found that whilst some incidents were discussed at staff meetings safeguarding concerns and their outcomes were not discussed. This meant there was a missed opportunity for staff to learn from safeguarding incidents.

Staff worked with people to understand and manage any associated risks. Staff supported people safely which was in line with their needs and wishes. People told us they were encouraged to take positive risks. The manager had reviewed staff training to ensure they could support people safely. Staff had guidance in place to support people safely. For example, we reviewed records for a person who was at risk of falls, the care plan detailed what support and equipment the person needed. This reduced the risk of the person receiving unsafe care and support. People told us staff knew them well which made them feel safe. A person we spoke with said, “Staff come and see me, check up on me. I feel very safe here.” People were encouraged to take positive risks to maintain and increase their independence. For example, a person told us, staff encouraged and supported them to get back on their feet following a fall. We found care records in place regarding independence supported this feedback. This approach meant people’s physical and mental well being was fully considered which improved people’s quality of life.

The provider did not always detect and control potential risks in the care environment. We found risks associated with the environment were not always managed to ensure people were protected from the risk of harm. We found areas of the home to be cluttered, including a corridor which people walked through. Unnecessary items can become an obstacle which increases the risk of a person falling over them. We also found items to be stored unsafely on the tops of wardrobes and shelving. These items could fall if furniture was knocked which could cause injury to staff, visitors and people living at The Hollies. We also found a towel rail in a person’s bedroom which had no safety cover over it and was very hot to touch. This is not in line with health and safety guidance and could cause burns or scalds. We fed this back to the manager who took action to reduce the risk to people during the assessment.

Staff were kind and caring, however we received mixed feedback from people about the number of staff on duty. A person we spoke with told us, “Staff do struggle sometimes, they could do with more. Staff are very good though.” Another person we spoke with told us, they sometimes did not have a shower at their preferred time due staff availability. Whilst we observed there were enough staff on duty during our assessment, we found staff were not always available to support people in the communal lounge, this was despite a person sat in the lounge needing support at times throughout the day. We found when staff were alerted, they responded without delay. We fed this back to the manager who told us they would address staff deployment. The manager told us, they had reviewed staffing levels and recently increased them to ensure people were safe. Staff completed training and had their competencies assessed. The manager had introduced new recruitment processes to ensure all staff were recruited safely and inducted into the service.

Infection and prevention control measures in place were not always effective. Parts of the home were in a state of disrepair meaning it could not be cleaned effectively. We found some walls to have bare plaster and many door frames and skirting boards to be chipped. This meant these areas could not be cleaned effectively. This posed a risk to people in the event of an outbreak of infection. We also found some equipment such as cushions and falls mats to be unclean. There was no cleaning trolley, which meant staff could not easily access cleaning products without touching all items within the basket staff were using. The manager told us they were aware of the issues relating to the storage of cleaning products, due to the layout of the building, a trolley was not suitable, they told us they were actively trying to find a solution. The communal lounge and bedrooms were clean and tidy, people told us, “The housekeeping team are very good, they help keep my bedroom lovely and tidy.” Internal processes had not always identified areas for improvement and there was no formal environmental improvement plan in place. The provider was receptive to our feedback and told us they were committed to improving the service.

There were processes in place to manage the storage and administration of medicines. However, some processes needed further work to ensure risks were minimised. For example, we found where people needed medicines as and when, staff did not always have clear guidance when these could be given safely. We found a person who required a sedative medicine had no maximum dose recorded. We also found not all prescribed topical creams had opening dates on them. Which meant staff did not know if these were safe to use or be assured of their effectiveness. This increased the risk people could receive their prescribed medicines unsafely. We found staff received training in medicines administration and had their competency assessed. We also found medicines were stored safely in line with best practice guidance. People told us, staff supported them with their medicines which made them feel safe.