Holly Tree Lodge EMI 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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. Accidents and incidents were recorded and used to formulate training sessions for staff to support learning from incidents. The registered manager understood their responsibilities relating to duty of candour. When incidents happened, notifications were made to the appropriate authorities.

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. Where appropriate the service shared information with health and social care partners to ensure there was safe care delivery. Records showed staff at the service recognised the need for support from health and social care professionals and made appropriate referrals in these instances.

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. The provider worked in accordance with legal requirements in relation to deprivation of liberties. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, 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. We found that where required appropriate referrals were made to the authorising authority. Staff at the service understood how to identify, record and report concerns of a safeguarding nature.

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. The provider worked with people to understand what was important to them and how they could be helped to manage risks proportionately. Where people required support to manage their health needs, the provider ensured relevant professionals were involved in decision making and care planning. Where people may find certain interventions distressing, such as a hospital admission, plans were in place to minimise incidences and information was available about how to support the person.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider ensured that a robust schedule of maintenance checks was in place, including regular environmental and equipment cheeks. Regular walk arounds of the service were completed to ensure standards were maintained.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Observations of care showed there were sufficient numbers of staff deployed to meet people’s needs. Staff appeared to know the people they were supporting well, and care was delivered in a way which was kind and compassionate. The registered manager ensured that training was up to date across the workforce and staff undertook regular supervision. Recruitment was completed safely and in line with current legal requirements.

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. All staff had access to adequate stocks of personal protective equipment and used this appropriately. The environment was clean and well maintained, a dedicated domestic team undertook regular cleaning duties and checks to ensure standards were maintained.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medicines as prescribed, which was administered by staff with appropriate training and competence to do so. Areas where medicines were stored were clean and well organised. Records showed that regular audits of medicines management were undertaken by the provider.