Holly Grange House Care 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.

This is the first inspection for this newly registered service. 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 service was in breach of legal regulation in relation to staffing.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff told us they were notified of accidents and incidents and any lessons to be learned were shared with the team. One staff member explained, “An email will go out to everyone and when you come in on shift there is a letter that goes round that shows what we've learnt. We all sign it.”

Staff told us there was an open approach to learning from mistakes to improve their individual practice. One staff member told us, “I made an error on my documentation, so we talked about how I could improve. It wasn’t a blame thing.” Another staff member said, “We don’t point fingers. If something is wrong, we own it and then we learn from it." The registered manager emphasised the importance of positive learning from adverse incidents and commented, “We need to empower the team to learn and mitigate the risks, so they don't happen again."

Accidents and incidents were reviewed at regular clinical meetings and any emerging trends shared with staff. The registered manager gave examples of how issues had been addressed through further training, reflective practice, competency discussions and the introduction of improved processes to drive improvement.

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, including when people moved between different services.

Relatives described safe processes to support their family member to transition to Holly Grange House. One relative told us, “They (managers) spoke to the hospital and had lots of conversations with me in the week leading up to the move.”

Information was shared with other healthcare professionals when people needed prompt support owing to health emergencies. This included information about any risks to people's health, their medication and their wishes for future care.One staff member explained, “All the residents have a hospital passport. If they go to hospital all the information is there so the nurses know what the resident needs are and what they like or don’t like.”

There were processes to ensure people’s external healthcare appointments were known and planned for. This included information about whether people needed support to attend the appointment or if transport needed to be arranged.

Staff advocated for people to ensure their safety when moving between services. One person had an imminent hospital appointment booked, which required them to fast prior to the appointment. Due to a recent change in their health, staff identified fasting may not be safe for the person and had contacted the hospital to rearrange the appointment.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated 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.

People generally felt safe living at Holly Grange House Care Home. One person told us, “The staff and the surroundings make me feel safe.” Another person said, “There is normally someone around to make sure that nothing goes wrong.” However, some people mentioned they did not feel so safe when there were high numbers of agency staff who did not understand their needs as well as permanent staff.

Staff were able to describe what incidents would be safeguarding events and knew when and how to report them. One staff member said, “I've never had to report anything, but if I had concerns, I would go immediately to a senior.” Another staff member told us, “I know what is right and what is wrong. My first stop would be management if I thought something had happened. I wouldn’t hesitate. I look out for all the residents because that is part of my job.”

The registered manager understood the importance of keeping people safe and protected and was clear what needed to be reported to us, CQC, and the local authority safeguarding team. Where safeguarding incidents occurred, appropriate action was taken to protect people and reduce the risk of recurrence.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care home, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. When people were identified as potentially being deprived of their liberty, applications were made to the authorising body as required. Processes were in place to ensure Deprivation of Liberty Safeguards (DoLS) were managed in accordance with legislative requirements.

The provider did not always work well with people to understand and manage risks. Care plans did not always identify risks to people and provide clear guidance for staff on how to support people safely.

One person was diabetic and had recently suffered from symptoms related to their diabetes, including the need for emergency care and treatment. Despite the known risk, there was no diabetic care plan in place to inform staff on how to safely manage the associated risks or respond to signs of deterioration.

Another person required regular repositioning to prevent the risk of skin damage. There was conflicting information in care records about how often this should be completed, with some notes saying 2 hourly and others saying 4 hourly.

The registered manager took immediate action in response to our feedback and either introduced or updated the care plans accordingly.

Other risks were well managed. For example, staff had access to detailed risk management information for people with clinical needs, including catheter care and specific health conditions. However, the use of complex clinical terminology and lengthy care plans meant information was not always presented in a clear and accessible way. This could impact staff's ability to quickly identify and follow key guidance when providing care and support.

There was evidence demonstrating how people had been involved in making decisions about their care and support. For example, where people expressed a wish to manage some of their medication independently, this was risk assessed and agreed where it was safe to do so.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People described a well maintained and secure environment which made them feel safe. One person told us, “The doors are locked downstairs; this makes me feel safe.” Another person said, “The structure and the facilities are excellent; I do feel safe.”

The provider’s systems and processes ensured the building and equipment were regularly inspected, serviced, and maintained to a high standard. The home was welcoming and well presented.

Staff told us they knew how to report concerns in the environment or with any equipment. One staff member explained, “Every day when you’re on shift you look out for anything that could be a risk. We do it to keep the residents safe. There is a book that you write things in like a repair, so the maintenance man knows what needs to be done.”

Permanent staff demonstrated a good understanding of their responsibilities and the actions to take if the fire alarms activated. They told us in the event of a fire they would go to the fire panel and await further instruction.

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.

People told us there were not always enough staff to meet their needs. One person said, “They are almost permanently short staffed, they can't get enough staff to get me out (of bed).” Other comments included: “They could do with more staff; they also use a lot of agency staff”, “The staff are very busy, there is not enough staff”, “They are short staffed, but they work hard” and “There is a shortage of staff, they try so hard. They always draft in agency staff.”

Permanent staff consistently told us they did not have time to deliver safe and personalised care. They told us staff vacancies and high levels of staff sickness meant they sometimes worked short staffed. One staff member told us, “I don’t think there are enough staff. There are a lot of shifts not covered. There is a lot of sickness. Some staff don’t pull their weight, and others go over and above. That’s probably why they go sick; because they are stressed.” Another staff member said, “We have vacant posts. They are always trying to recruit. Staff just don’t stay and staff often call in sick at the last minute. It’s not fair on everyone. They try to get agency but that takes time, and it’s usually in the morning that we work short. I see it happen all the time.”

The provider used a dependency tool to identify required safe staffing levels in the home. However, rotas demonstrated staffing numbers were not consistent and there was variance in the day-to-day allocation. The dependency tool did not consider the competence, skills and knowledge staff had of the individual needs of people living in the home.

We reviewed the call bell response times for the 7 days prior to our inspection and found 142 call bells had been unanswered within the provider’s expected timeframe of 5 minutes. 139 of these had exceeded 10 minutes, and on 19 occasions call bells had been unanswered for over 30 minutes. One person, who was cared for in bed had a call bell ringing for 58 minutes. Another person had 12 calls not answered within 10 minutes over the 7-day period and the longest wait was 40 minutes. One staff member told us, “We do our best, but the reality is they (people) have to wait. If we are in with another resident, then there is no one to help.”

On the day of our inspection there were 9 care staff on duty and a unit manager. Five of the care staff were staff employed through an agency, 1 who had never worked in the home before and 1 who had worked there once before. Although staff numbers had been maintained, permanent staff had to spend time explaining to agency staff how to support people safely and provide care in the way people preferred. One staff member described having to monitor and instruct new or agency staff. They told us, “I'm exhausted trying to delegate and explain. I have to explain everything. And it's been like that for a few months.”

Profiles were in place to demonstrate agency staff had received the required training and necessary employment checks before working at Holly Grange House Care Home. Short inductions had been completed for these staff but were not adequate to ensure they knew what support people needed or how to respond in an emergency. Not all agency staff were able to record information in people’s care records on the electronic care planning system. One person told us, “The regular staff are well trained but only some of the agency staff are.”

Staff recruited by the provider, were recruited safely and all necessary checks were completed before they started work in the home. However, managers could not provide evidence of induction processes for recently appointed staff. One staff member had started working at the home in January 2026 with no record of their induction into the role, evidence of competency checks or probation meetings on file. The provider’s quality improvement manager told us they had identified this recently and had put plans in place to improve induction processes, competency checks and probation reviews. New induction booklets were being introduced and were to be retained in files once completed.

The provider was actively recruiting and onboarding new staff at the time of our inspection visit.

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.

People spoke positively about the standards of cleanliness within the home. One person told us, “I can’t fault it; it is clean and tidy.” Another person particularly spoke about how well their laundry was managed, describing it as, “Perfect.”

During our inspection we found all areas of the home were clean and tidy with no visible infection prevention and control concerns identified.

Staff had completed infection prevention and control training and demonstrated that they knew when to wear appropriate personal protective equipment (PPE). Staff said PPE was accessible and available when needed. However, the provider’s dress code policy was not applied consistently by all staff. For example, some staff continued to wear jewellery when working which could potentially impact on maintaining good hygiene. The provider’s quality development manager assured us the policy would be revisited with managers and staff.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People raised no concerns about the management of their medicines and told us they were available when they needed them. Comments included: “I do have medication and they never forget to give it to me”, “I have loads of medication, they are late sometimes but never forget” and “The girl who gives the medication is very good.”

Medicines were stored, administered, and disposed of safely in line with the provider’s procedures and best practice guidelines.

Staff responsible for the administration of medicines had completed training and their competency had been assessed. Staff were observed taking their time when administering people’s medicines. People were informed what their medicine was for and asked if they were ready to take them. One staff member confirmed, “Agency staff are not allowed to do medication. It is only the senior team and management. You have to do your training, and you have to be observed to make sure you are doing it safely.”

Records and checks demonstrated people had received their medicines as prescribed. However, we found some improvement was needed to ensure staff had the information they needed to manage topical creams and administer ‘as required medicines’ consistently. The care manager responded positively to our feedback and assured us guidance in people’s medication records would be updated with more detail.