Holly Cottage

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

At our last assessment we rated this key question Good. At this assessment the rating has changed to 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. We observed people receiving care from staff who understood their needs. However, there were shortfalls found within the care planning documents reviewed which meant there was a risk people might not be supported safely. The provider had invested resources to upgrade the heating system but this had exposed people to the risk of scalding. Other areas of the service were well maintained. Incidents and accidents were not always recorded or reported accurately, and we found some incidents that had not been shared with the relevant external regulatory bodies. The provider was in breach of legal regulation in relation safe care and treatment. There were enough skilled staff during the day, but we were not assured night staffing ensured people’s repositioning needs could always be met.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff listened to concerns about safety, but we were not assured that concerns were always investigated and reported due to gaps in recording. Accidents were recorded in a timely manner within people’s care notes, but we did not see how these were analysed and managed to reduce future risk. There was no central log for accidents and incidents for the location which made oversight challenging. We brought this to the attention of the manager, and they have since taken action to address this. We found the service worked well with other external agencies and responded to action plan requests. The provider ensured that any learning was passed down to the staff team through training, team meetings, and supervisions. Most of the training was provided in-house. The manager told us that events within the location were integrated into the training, and staff received frequent coaching sessions following incidents. Complaints were not always considered as an opportunity for learning. There had been a whistleblowing notification which had been investigated and closed by partner organisations. However, the manager had not recorded this as a complaint, and consequently there were no lessons learned, or outcomes shared. Lessons were not always learnt to continually identify and embed good practice.

The provider did not always manage or monitor people’s safety robustly. They worked with healthcare partners to establish and maintain safe systems of care when people moved between different services. We found people had care plans and risk assessments in place and staff knew people’s needs. However, care plans and risk assessments did not always contain consistent or enough information on how staff should support people to manage specific risks. For example, one person was assessed to have an Eton Constipation score of 29, meaning the person was at high risk of constipation, but there was no record of what action or processes staff should follow to mitigate this risk.

A healthcare professional we spoke with told us, ‘When new residents are seen by me, a full medical history is taken. Staff have always been able to provide this along with a current list of medications.’ The manager and staff told us that they got to know new people well during a transition period prior to moving into the service.

Processes were in place to protect people from abuse and staff received training. The safeguarding log we reviewed was not fully completed with dates missing and no clear documented process of when concerns had been shared with the local authority and CQC. Safeguarding concerns had not always been appropriately notified to CQC. It was not clear from this how the service carried out its responsibilities to report and act on all safeguarding concerns. 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. Safeguarding information was available, including contact numbers and posters, and there was a whistleblowing poster in place. There were also contact details for the local authority safeguarding team and CQC.

The provider did not always work well with people to understand and manage risks. Staff had received positive behaviour support training and told us how they supported people in crisis. There were monitoring charts in place, but these were not completed consistently which meant we could not be fully assured people were being supported safely. People had behaviour support plans in place which identified possible triggers for their distress reactions. However, these did not offer detailed de-escalation techniques and person-centred approach to supporting people in crisis. Staff told us they knew how to support people in the event of a fire evacuation. However, care plans and risk assessments did not always contain clear information on how staff should support people. For example, one person’s personal emergency evacuation plan (PEEP) stated they were able to open a fire exit door themselves. Their care plan stated their mobility was poor and they required the assistance of one staff member to move safely and were often cared for in bed.

The provider had systems in place designed to assess and mitigate risks in the care environment. However, systems did not always ensure equipment, facilities and technology supported the delivery of safe care. For example, as part of an upgrade to the heating system new radiators had been installed. We found these radiators did not have covers which meant they were hot to touch and risked causing burns. This was a documented risk in the manufacturer’s handbook. Some radiators had not been secured to the walls which led to a further risk of injury. These risks had not been identified and mitigated. We found that recommendations from an inspection of the fire alarm and detection systems dated 25 July 2024 had not been actioned. We also identified a concern with pests in the loft had not been promptly and robustly addressed by the provider. Other routine health and safety checks were completed on time and records confirmed this.

People had agreed hours of support and there were always enough staff to meet people’s commissioned hours during the day. We were not assured that the provider had safe staffing levels at night with the level of support needs of the people living at Holly Cottage. At the time of our assessment, staffing levels for nighttime were 1 waking night staff and 1 sleep-in staff. One person’s care plan stated that they needed to be repositioned every 4 hours at night, however it did not detail how this is safely achievable with 1 staff member, given the person needed 2 staff to assist them.

The provider made sure staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. We observed staff supporting people in a polite and dignified manner.

The provider had recruited predominantly overseas staff. To facilitate a swift transition, the provider had designed a specific training for the international staff focused on living and working in the United Kingdom. Staff we spoke with were knowledgeable about the people within the service and worked together as a team to achieve the best outcome for them. Staff were keen to give us feedback, and took pride in their roles, and the support they were able to offer people.

The provider assessed and managed the risk of infection. There were systems designed to detect and control the risk and spread of infection. We viewed one person’s bedroom which was free of clutter. They were supported by staff to keep their room and clothes clean.

The service was clean throughout. The kitchen was well organised, staff were observed using the right equipment and personal protective equipment (PPE) to complete cleaning tasks. There were no odours or clutter. Food hygiene procedures were followed during meal preparations, and all food within the property was in date. Legionella checks were carried out regularly. The location had received 5 stars rating from the Food Standards Agency. The provider had recently renovated some of the downstairs bedrooms with further works planned for the upstairs.

Although the provider aimed to ensure medicines were administered safely and met people’s needs, we identified some areas which needed improving. For example, one person had been assessed within the care plan as having an allergy to penicillin, but this information was not reflected within their medication plan. This inconsistency placed the person at potential risk of harm. We also noted there had been a medicines error on 6 July 2024. We found no evidence of lessons learnt from this or thorough investigation.

Staff were involved in planning for people’s medicines needs, including when changes happened. People’s medicines were stored in individual locked cabinets, and we observed staff supporting people to take their medicines safely.

The service worked collaboratively with external health professionals and aimed to ensure the best outcomes for people. The service had a weekly review of people’s health with the local GP practice.

The provider told us that they worked with health professionals, to ensure that people’s medicines were routinely reviewed and adjusted based on their current needs. The service had a named member of staff as main point of contact for all medicines related queries.