Holly House Care Home

Updated 11 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 1 inspector.

Service and service type

Holly House 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. Holly House is a care home without nursing care. 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.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals 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.

We reviewed public information available on the Healthwatch website. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

During the inspection

We spoke with 2 people who used the service and 3 relatives. We spoke with the registered manager, who is also the provider, the deputy manager and 4 staff that included catering, training and care staff. We also spoke with the nominated individual, who is responsible for supervising the management of the service on behalf of the provider.

We reviewed the care records for 6 people who used the service and a selection of medicines administration records for people. We observed the care and support provided by staff and the home environment was assessed for safety and suitability. We also looked at 3 staff recruitment records, the provider’s policies, quality assurance audits and action plans.

Updated 11 October 2023

About the service

Holly House is a residential care home providing personal care to up to 9 people. The service specialises in working age dementia providing care to younger adults living with dementia and mental health conditions. At the time of our inspection there were 9 people using the service.

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

Care plan review records lacked involvement from people, their relatives and representatives. In addition, for people who lacked capacity it was not always clear how they or their representative had been involved.

The provider had safeguarding systems and processes to keep people safe. Staff knew about the risks to people and followed the assessments to ensure they met people's needs. People felt safe and were supported by staff who knew how to protect them from avoidable harm.

People received their medicines safely and as prescribed and were supported by sufficient numbers of staff to ensure risk of harm was minimised.

Staff sought people's consent before providing care and support. People's individual communication needs were considered to support them to be involved in their care.

Staff spoke positively about working for the provider. They felt well supported and that they could talk to the management team at any time, feeling confident any concerns would be acted on promptly. They felt valued and happy in their role.

Staff had been recruited appropriately and had received relevant training, so they were able to support people with their individual care and support needs.

The home was clean with effective infection prevention control measures in place to mitigate the risk of cross contamination.

There were processes in place to monitor incidents and accidents to identify potential trends and put in place action plans to reduce risk of reoccurrence.

People’s needs were assessed before joining the service. Staff completed a 12 week training induction when they first started with ongoing training to maintain their skills.

People’s nutritional needs were being met. The service worked effectively with health and social care professionals and services to maintain the health and wellbeing of people.

The home environment was bright and spacious with a number of different areas around the home for people to relax in.

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 and relatives told us they found the staff to be kind and caring. People’s independence was encouraged, and they were treated with dignity and respect by the staff.

There had been few complaints made about the service. However, there was a complaints process in place that monitored for themes to reduce risk of reoccurrences. The provider had processes in place to support people who were approaching their end of life.

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 25 October 2017).

Why we inspected

The inspection was prompted due to concerns about the number of people living at the home. A decision was made for us to inspect and examine those risks.

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.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.