You are here

The Hollies and Hollies Lodge Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 13 September 2018

The inspection took place on 4 July 2018 and was unannounced. The last inspection to this service was carried out on 19 December 2016 and was rated good throughout with no breaches of regulation. According to our inspection methodology this service did not require an inspection for thirty months. However due to concerns received about the service from a whistle blower and several concerning notifications we brought the inspection forward. During our inspection on 4 July 2018 we found this was no longer a good service and identified breaches of regulation around person centred care, consent, safe care and treatment, staffing, the premises and equipment and clinical governance. Since the last inspection the registered manager had left and a new manager came into post in November of last year. They told us they had made some significant changes to the service and had in place a detailed action plan they were working towards. We were confident in the manager’s ability to identify and bring about positive change to the service. We were less confident in the overall management and oversight of the service by the registered providers.

The service is registered for up to 27 people who primarily have a mental health need. However, people might also have a learning disability, a diagnosis or autism or issues relating to alcohol and substance misuse.

The Hollies and Holly Lodge is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is divided into two separate units joined by corridors. The main house accommodates most people and has shared communal areas and communal showers. It offers single occupancy bedrooms and generous gardens and grounds. The second part of the building has fewer number of people and separate communal facilities and separate staffing.

During our inspection on 4 July 2018 there was a manager in post but they were not yet registered with the Care Quality Commission although they advised us they had put their application in and had been waiting at least twelve weeks.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found people were receiving care that was not always safe or met their identified needs. The manager had taken actions to try and ensure people got their medicines as intended after a series of medication errors. This had resulted in either people not getting their prescribed medicines or medicines administered incorrectly. There had also been issues with accounting for medicines to make sure they were available as people needed them. The manager had put more robust procedures in place and had supported staff to ensure they were competent and had accessed the right level of training.

The manager confirmed they had significantly increased the staffing levels since coming into post including the introduction of waking night staff. However, we were unable to see what people’s assessed needs were as some people had not been reviewed for some years. Some people had high risk behaviours which could put themselves or others at risk. Staffing levels meant that people were not always supervised for their safety and were not sufficient for people to have personalised care around their needs. The service did not have a dependency tool in place to show how they calculated the numbers of staff they needed.

The environment was not safe for its intended use. We found during our inspection broken window restrictors, ligature risks, uncovered radiators, water that exceeded recommended temperatures, and exposed

Inspection areas


Requires improvement

Updated 13 September 2018

The service was not safe.

People did not always receive their medicines as intended.

Risks from the environment were not carefully controlled. Risks to people’s individual safety was not always reduced adequately.

Staffing levels were not adequately assessed to ensure they met people’s individually assessed needs.

Arrangements in place to reduce the risks of cross infection were insufficient.

Staff understood how to keep people safe from abuse and report any concerns they might have both internally or externally where necessary. However, we could not see how staff learnt from adverse events or how the service was proactive in supporting its staff to manage incidents effectively.

Staff recruitment processes were sufficient to help ensure staff employed were safe and had the right skills and attributes to work in care.


Requires improvement

Updated 13 September 2018

The service was not effective.

There was poor recording of capacity assessments for those who had fluctuating capacity and might need support to make decisions or have decisions made in their best interest.

There was poor recording of how people’s health care needs had been monitored or if people had adequate access to health care professionals.

People were supported to eat and drink sufficiently and the risks of unintentional weight loss were monitored. However, some people were putting on weight and this had not been considered in relation to increased health risks.


Requires improvement

Updated 13 September 2018

The service was not always caring.

People had privacy but the environment did not lend itself to people being able to have private space unless in their rooms and even then, their personal space could be compromised.

People were supported according to their wishes and needs but also according to the availability of staffing.

People were consulted about their wishes and needs.

Staff were observed talking to people in a respectful way and knowing people sufficiently well.


Requires improvement

Updated 13 September 2018

The service was not responsive.

Peoples care plans were not always sufficiently up to date and did notreflect people’s changing needs. Daily notes did not show how people’s needs were being met or how people were encouraged to retain existing skills.

Activity during the day was limited according to people’s interest and motivation to participate. However, we did not see sufficient opportunity for staff to spend time with people and encourage them to join in or participate in an activity of their choice.

There was an established complaints procedure and people could feed back about their care, support and treatment and concerns were acted upon.


Requires improvement

Updated 13 September 2018

The service was not well led

The new manager was waiting for CQC registration. They were very experienced and had made a positive impact on the service.

Prior to them coming into post there were clearly some shortfalls which had not been recognised by the provider and had affected the safety and security of those using the service.

Some people’s needs had not been assessed and we were not confident that the service had the necessary staff in place with the right skills to meet people’s needs.

The service was not complying with all the regulations.

We had concerns about the safety and suitability of the premises and will be seeking assurances from the provider that this will be dealt with immediately.