Holly House Residential Home

Updated 5 October 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 2 inspectors.

Service and service type

Holly House Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity started on 15 August and ended on 21 August 2023. We visited the location on 15 August 2023.

What we did before the inspection

We reviewed information we had received about the service since becoming registered. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 7 people and 6 relatives of people who used the service about their experience of the care provided. We spoke with the provider, registered manager and deputy manager. We also spoke with 5 care staff. We reviewed a range of records. This included 5 people's care records and multiple medication records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 5 October 2023

About the service

Holly House Residential Home is a care home providing accommodation and personal care to up to 28 older people and people living with dementia. At the time of inspection there were 27 people living at the service.

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

People continued to be cared for safely and with compassion. Staff were appropriately recruited and there were enough staff to provide care and support to meet people’s needs.

Effective systems were in place to identify and manage risks to people. These included individual risks such as falls and pressure ulcers and environmental risks.

People were supported by sufficient numbers of staff who knew them well and understood how to meet their needs.

Medicines systems were well organised, there was effective oversight of medicines in place and people received their medicines as prescribed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were protected from infection and the home was well maintained and clean.

The service had a positive ethos and an open culture. The management team were approachable, understood the needs of people, and listened to staff. People that used the service and their relatives had the opportunity to feedback on the quality of the support and care that was provided. There were effective systems in place to monitor the quality of the service and drive improvements.

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 rating for this service was good (Published 15 November 2022).

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of people’s skin and pressure ulcers and meeting people’s health needs. We undertook a focused inspection to examine those risks and reviewed the key questions of safe and well-led only.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well led sections of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

The overall rating for the service has remained good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Holly House Residential Home on our website at www.cqc.org.uk.