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The Hollies Requires improvement

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 September 2021

About the service

The Hollies is a residential care home providing personal care to people aged 65 and over, some of whom are living with dementia. At the time of the inspection there was 28 people using the service. The service can support up to 28 people.

People’s experience of using this service and what we found

We found the staffing levels were not adequate. There were limited activities organised for people however, the service is in the process of recruiting an activity co-ordinator.

The service reported a high number of unwitnessed falls over the previous 12 months. We were not assured that systems were always in place to take action to reduce these. Equipment such as stair safety gates and handrails had been fitted to improve safety in the environment.

There was a lack of effective governance systems. We found some policies were out of date or had no review date, the registered manager stated this would be actioned.

We found risks were not always managed in the least restrictive way. We recommend the provider works within the principles of the Mental Capacity Act 2005 (MCA) to determine whether alternatives could have been considered rather than using restrictive practices.

During our inspection we found issues with medicines storage and administration. We were not assured the service reviewed medicines and records were not always complete. People at the service felt supported to take their medicines, one person told us, “I feel supported to take my tablets on time.”

People told us they felt safe living at The Hollies. The provider had effective safeguarding systems in place. Staff demonstrated a good understanding of how to raise safeguarding concerns.

People and staff provided us with positive comments about the management team “if I need help, I know I can ask”. Staff said they felt supported. We found the management team had taken steps to improve the service.

The service had established good working relationships with health professionals, one health professional told us “the staff are always friendly and approachable”.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last inspection was not rated and there were no breaches (published 27 November 2020). At the last comprehensive inspection the service was rated requires improvement overall published 28 January 2020.

Why we inspected

This was a planned inspection and was prompted in part by notification of a specific incident. Following which a person using the service sustained a serious injury. The information CQC received about the incident indicated concerns about the management of falls from stairs. This inspection examined those risks.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Hollies on our website at www.cqc.org.uk

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence the provider needs to make improvements. Please see the Safe and Well led sections of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to managem

Inspection areas

Safe

Requires improvement

Updated 21 September 2021

The service was not always safe.

Details are in our safe findings below.

Effective

Requires improvement

Updated 21 September 2021

Caring

Good

Updated 21 September 2021

Responsive

Good

Updated 21 September 2021

Well-led

Requires improvement

Updated 21 September 2021

The service was not always well-led.

Details are in our well-led findings below.