Hollyveer 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 service under the current provider.

This key question has been rated 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 provider was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (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 demonstrate a proactive and positive culture of learning in order to improve people’s safety. Managers did not robustly analyse people’s health monitoring records to identify and address concerns relating to their health needs. This meant it was not always clear how any change or deterioration in people’s needs was being monitored to ensure their safety. Lessons learnt from incidents and safeguarding concerns were brief and lacked specific detail about what measures were being put in place to minimise future risks.

The provider worked alongside healthcare partners to establish and maintain safe systems of care when people moved between different health services. The provider shared information with other health professionals when appropriate to support people’s needs and provide continuity in their care.

The provider did not always work well with people to understand what being safe meant to them. Where concerns were raised with the provider, they had not always responded appropriately to ensure people felt protected and listened to. The provider had not always shared concerns promptly to ensure concerns were investigated.

The provider did not work well with people to understand and manage risks. People did not always have accurate, detailed risk assessments in place to provide staff with guidance about how to support them safely. Daily care records relating to people’s health care needs, such as food and fluid intake, were poorly completed and monitored. Risks relating to falls and weight loss had not been managed effectively to address the underlying concerns and minimise risk. The provider had not ensured all people living in the service had up to date and accurate personal emergency evacuation plans (PEEPs) to enable staff to support them to evacuate safely in the event of a fire. Some PEEPs remained in place for people who were no longer living in the service. This meant the fire service may not have accurate information about who was in the building in the event of an emergency. Following our feedback, the provider confirmed they had reviewed and updated people’s risk assessment documentation and PEEPs.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. During the site visit, we found equipment used to alert staff when a person had fallen was not placed appropriately. Following our feedback, the provider implemented additional checks to ensure this equipment was in the correct position. The provider was not able to produce an up to date fire safety risk assessment or fire equipment certificates during the inspection site visit. The documentation reviewed on site was out of date. Following our inspection, the provider sent up to date documentation and confirmed this was now accessible on site.

People told us there were enough staff available to meet their needs. People and their relatives said there was a consistent staff team in place and they knew staff well. During the inspection we observed sufficient staff were available to provide support. Staff had received appropriate training relevant to their role. Staff were safely recruited with relevant employment checks completed.

The provider did not effectively assess or manage the risk of infection. They did not always detect and control the risk of it spreading. For example, we found stained and unclean flooring in multiple communal areas and bedrooms, and a build-up of dirt and dust in the communal hallways next to the kitchen. In the kitchen we found a used frying pan containing oil sat on a low shelf near the floor. Staff told us they did not wash the frying pan until the end of the day and reused the oil and pan throughout the day for cooking. Foil had been placed on the cooker top to collect spillages, this was heavily stained. Staff told us this was only changed on a weekly basis despite the spillages. The provider’s infection prevention and control monitoring had failed to identify these risks.

Staff ensured people’s medicines were safe and met their needs. Medicines administration records were completed accurately and medicines stock checks were correct. Staff had received medicines training and had their competency checked prior to administering it. People had protocols in place to provide staff with guidance about how to administer ‘as and when required’ medicines, such as pain relief. However, we found some of these lacked sufficient detail. Following our feedback, the provider confirmed these had been reviewed to ensure more detail was included.