Hollie Hill

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 rated assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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. They listened to concerns about safety, investigated and reported safety events. Systems were in place to ensure lessons were learnt to continually identify and embed good practice. Staff recorded and reported incidents. The interim manager carried out monthly audits of these to identify patterns and trends. They told us they would discuss findings with staff in team meetings to prevent reoccurrence.

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.

People’s needs were assessed before they moved into the service and individual care plans were created to guide staff on how to support people and meet their needs. The interim manager told us that often this was done by using information which had been provided by a trusted assessor. A trusted assessor is a qualified professional trained to conduct comprehensive assessments of health and social care needs. They act on behalf of multiple organisations providing a holistic evaluation of an individual’s needs, which helps streamline the assessment process.

People’s health conditions were documented, and they were supported to access services from a range of professionals, including specialist nurses and dieticians.

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 told us they felt safe at the service. One person told us, “Yes, I feel very safe here. The staff are nice to me and look after me.”

The interim manager was aware of safeguarding incidents which needed to be reported to the local authority. They told us they worked with the safeguarding team to review incidents and take action where needed. Staff were provided with safeguarding training and understood what needed to be reported.

Where appropriate the provider had applied to the local authority for Deprivation of Liberty Safeguards (DoLS) authorisations. Details of all DoLS applications were included in care plans, including details of any conditions to the authorisations.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s health, safety and welfare had been assessed and risk management plans were developed to manage those risks. Risk management plans had been regularly reviewed as people’s needs changed. Staff had access to updated information about risk through care plan records as well as daily handover meetings.

People had personal emergency evacuation plans (PEEPs) in place which detailed potential hazards at the service and how to safely support people in the event of an emergency.

The provider did not always detect and control potential risks in the care environment.

We undertook a walk around the service and observed the premises were showing signs of wear and would benefit from refurbishment. However, internally the premises was clean, free from hazards and equipment had been maintained in line with current guidance. Externally, we observed the rear of the premises was not secured by fencing or gated access at either side of the main building. This presented a potential risk to the safety of people using the service, including those subject to Deprivation of Liberty Safeguards (DoLS) authorisations, as well as to the security of people’s personal belongings. This was discussed with the leadership team who were receptive to feedback and reassured us that no incidents had previously occurred. The interim manager later advised us that a contractor had been contacted to provide a quote for this work to be undertaken.

Fire alarms were tested regularly, and detailed records were maintained for all servicing and checks. The interim manager carried out regular audits of the home and environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

The interim manager told us they used a tool to calculate staffing levels and based on current dependency levels; the service was operating above recommended staffing levels.

However, during observation of the lunchtime meal service in one area of the home, we noted that only two staff members were supporting people both within the dining area and in the adjacent hallway, where some individuals were being supported in their rooms. This limited level of oversight increased the potential risk to people not receiving safe care.

We raised our concerns with the leadership team, who acknowledged the issue and took immediate action to review and increase staff deployment to ensure people’s needs were met safely.

People we spoke with did not share any concerns about staffing. They told us at times staff looked like they were rushing but people had the support they needed in a timely way. Comments from staff about staffing numbers was mixed. Some felt there was enough staff to safely meet people’s needs, whilst others told us there were times when there were not enough staff.

The provider did not always assess and manage the risk of infection.

The environment was clean and well maintained in terms of hygiene, with no unpleasant odours noted. However, some areas appeared worn, which may impact the effectiveness of cleaning. We shared this feedback with the leadership team, who confirmed they were aware of the issues and had an ongoing maintenance programme in place to refurbish and improve parts of the internal environment.

All necessary personal protective equipment (PPE), including gloves and aprons, were available in full supply, with no shortages observed. People told us they saw staff wearing the correct PPE at all times. Staff had regular training on infection prevention control (IPC) and had support to maintain skills for areas such as handwashing.

The provider did not always make sure that medicines records were kept up to date.

The provider had recently introduced a new electronic medication management system. During our review of records held within this system, we identified shortfalls in the quality of information recorded for people who required covert administration of medicines and for ‘when required’ (PRN) protocols.

We shared this feedback with the interim manager, who acknowledged our concerns and explained that paper-based records were still being maintained while information was being transferred onto the new system. The interim manager subsequently demonstrated that records had been reviewed and updated to improve accuracy and completeness.