The Hollies Residential Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance. We found the provider did not always identify areas for improvement in a timely manner.

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.

Systems and processes in place required strengthening to ensure there was an open and honest culture. We found some incidents which had not been reported by the provider to the local authority or CQC, prior to the new manager starting. This included where a person had become seriously injured. We also reviewed a complaint response following an incident where internal processes had failed and as a result a person’s care suffered, the provider failed to apply the duty of candour. Duty of candour is the legal responsibility of health and social care providers to be open and honest when things go wrong. This duty is in place to promote transparency, accountability and learning from mistakes to improve safety. This meant there was not always an open and honest culture. The manager was open and honest about the issues at the service and told us they were working hard to improve the environment and gave us several examples of the work they had completed since starting at The Hollies, this included decorating an area of the home in line with people’s preferences. People and staff were encouraged to share their ideas at meetings. People and staff told us they felt listened to by the manager.

The manager was experienced and understood the context in which they delivered care, treatment and support. The manager had good oversight of staff and people’s needs. However, provider oversight was not effective in identifying issues. We found external organisations such as the local authority, infection control team and fire service identified concerns rather than the providers internal processes. For example, the fire service had been out and completed an audit with a number of issues found, which had not been identified internally. The local authority also raised concerns about staffing numbers during the night at the service and the impact this had on emergency evacuation plans. The provider had implemented a process which instructed staff to attend the home in the event of a fire, this was not in line with guidance and staff had no knowledge of this process. We found the manager completed audits of the service, but these were not reviewed by the provider. This meant there was no oversight of the managers performance. Meetings were held between the manager and provider however the minutes reviewed did not evidence governance arrangements were discussed. Staff told us, they were confident in the managers and deputy managers leadership skills.

Staff told us the manager was approachable and there was a no blame culture at The Hollies. Staff said if they had concerns, they would raise these with the manager. However, staff told us they did not feel confident in raising concerns outside of the manager and there had previously been a poor culture at the home which some staff were still worried about. Staff we spoke with were not confident in the whistleblowing process; they were unaware whom they could share concerns about the service to. We fed this back to the manager who advised they would discuss whistleblowing with staff during supervision discussions. There was a whistleblowing policy available to staff, however this referenced a different care home and registered manager throughout. This indicated staff had not read the whistleblowing policy as this had not been raised as being incorrect.

Staff were supported by training and an equality and diversity policy. Staff told us the culture had improved since the new manager had started, however some staff told us at times morale had been low and they did not all feel they had been treated fairly. This continued to impact them and their willingness to speak up. The manager was committed to improving the moral and culture of the home to ensure care and support was not affected. Minutes we reviewed from meetings demonstrated the manager praised staff for their commitment to people living at the service.

Systems to audit the quality and safety of the service were in place however these were not always effective in driving service improvement. As detailed within this report we found issues relating to the environment, medicines and infection control. There was no service improvement plan in place detailing what needed attention and by what date. This meant there was no process in place to ensure issues were rectified in a timely manner. We found as detailed within this report areas for improvement were highlighted by external agencies rather internal processes. This meant the provider’s internal governance processes did not always identify areas for improvement. The provider had completed an audit but there was no detail in how, by who or when issues would be addressed. The provider discussed the challenges relating to the environment and told us they were committed to improving the environment for people living at The Hollies.

The manager understood their duty to collaborate and work in partnership with others. People told us they were involved in planning their care, they told us staff respected their privacy and choices. A person we spoke with said, “It’s up to me when I get up, decide what to wear and what time I want breakfast.” Staff told us they worked in partnership with health and social care partners to improve people’s experience. The hairdresser, audiologist and chiropodist all visited regularly. Staff said they had plans to assist people out into the local community and also had plans to develop areas of the garden to enhance people’s overall wellbeing.

The provider did not always focus on continuous learning, innovation and improvement across the service. There was a reactive approach to issues rather than proactive. This meant areas for improvement were repeated. For example, on our previous two inspections of the service we found issues with the cleanliness and clutter at the home. We found issues relating to the environment had continued, which meant the provider had not learnt from previous inspections. We found whilst some formal lessons learnt had been shared with the staff team this was infrequent. This was a missed opportunity to reduce risks and improve the safety and quality of care.