We carried out a review of the data available to us about Holly Hall House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Holly Hall House, you can give feedback on this service.
We found the following examples of good practice.
The provider was following best practice guidance in terms of ensuring visitors to the home did not spread COVID-19. On arrival visitors were asked to consent to a lateral flow test (LFT) and their temperatures recorded.
Where possible staff encouraged people to keep a safe distance from each other and there was additional cleaning of touch points in communal areas to mitigate the risk of cross infection.
People were supported to keep in contact with their family members through social media, phone calls, physical visits, or driveway and garden visits.
Staff were adhering to personal protective equipment (PPE) guidance and practices. There was a plentiful supply of PPE in a number of locations throughout the home including the front reception area.
Clear plans were in place for people who may be required to self-isolate.
Staff continued to support people to access healthcare and arrangements were in place should people need to attend hospital and return to the home safely.
Holly Hall House 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. Holly Hall House accommodates up to 10 younger people, with learning disabilities, physical disabilities, or mental health conditions, in one adapted building.
There was a registered manager. 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.
The registered manager and staff had received safeguarding training and were aware of their responsibilities in raising and supporting safeguarding. They knew what type of events would cause them to raise safeguarding concerns and who they would report them to.
The registered manager ensured people’s needs were met, by having sufficient staff, with the appropriate knowledge and skills. Safe recruitment practices were in place. Staff had access to training and supervision to support them in their role. Staff understood the importance of gaining peoples consent in keeping with the Mental Capacity Act 2005. The registered manager understood their legal responsibilities and had completed deprivation of liberty applications for those people whose liberty was being restricted.
Medicines were securely stored and safely managed and administered. Medicine recording charts were in use. On a few occasions records had been amended, by overwriting, making it difficult to determine the record. We discussed this with the registered manager who agreed to raise this issue with the staff.
Staff followed infection control procedures and used gloves and apron when assisting people with personal care or when preparing and serving food. We found the home to be clean and tidy. Food storage areas, including the fridge were clean and neatly stocked.
Relatives were involved in the planning and reviewing of care plans. The service had links with external health care professionals, examples included the district nursing service, physiotherapists, and day centres.
At this inspection we found Holly Hall House was presented in a homely way and to be odour free. There were some internal decorations in progress in the communal areas. There was a programme of building and equipment safety checks in place to keep people safe in their home.
We could see that staff had positive relationships with people. People were visibly happy, smiling and laughing with staff. Interaction between people and staff members was kind, friendly, and naturally caring. People were treated with dignity and given privacy. We saw staff knocking on people’s doors and gaining consent to enter.
The registered manager was supportive of training and staff were very positive about training events attended. We found that staff were proud to work for the service. They felt well supported by the registered manager.
The registered manager effectively analysed various quality assurance indicators and used this information to improve outcomes for people. The provider had notified us about events that were required to be law and had on display the previous care quality commission rating of the service.
Holly Hall House is registered to provide accommodation and personal care to a maximum of 10 people who may have learning disabilities or mental health needs. At the time of the inspection there were 10 people were living at the home.
There was a registered manager in post. 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.
Staff understood how to report concerns of abuse and manage risks to keep people safe. People were supported by sufficient numbers of staff who had undergone recruitment checks to ensure they were safe to work. However improvements were required with the systems in place to support staff who had declared health conditions. People did not always receive their medication as prescribed and records did not always reflect the reasons why ‘as required’ medicines where administered.
Staff had access to training and supervision to support them in their role. Staff understood the importance of seeking people’s consent in line with the Mental Capacity Act 2005. The registered manager understood their legal responsibilities and had completed Deprivation of Liberty applications for those people whose liberty was being restricted. People were supported to have enough to eat and drink and had been supported to access healthcare support when required.
People were supported by staff who were kind and treated people with dignity. People were supported to be involved in their care and maintain relationships with people important to them. Information was available for people should they need support from advocacy services.
People were involved in the planning and review of the care. People felt supported by staff who knew them well and were given opportunity to take part in activities that were meaningful to them. People and their relatives knew how to make a complaint if needed.
Audits were completed to monitor the quality and safety of the service however these were not effective in identifying shortfalls to enable improvements to be made. Records completed were not always an accurate reflection of people’s wellbeing.
Staff felt supported by their manager and the provider. People, relatives and staff were given opportunity to feedback on their experience of the service and felt able to approach the registered manager with any issues.
The provider is registered to accommodate and deliver personal care to ten people. At the time of our inspection ten people lived at the home. People lived with needs relating to their learning disability and/or mental health condition.
The provider changed their company name and re-registered with us in 2014. This was the first inspection under their new company name.
The manager was registered with us as is required by law. 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.
Although the registered manager and staff had received training on procedures they should follow to ensure the risk of harm and/or abuse was reduced they had not always followed them. They had not notified the local authority safeguarding team or us of an incident of physical aggression as they should have done to ensure the person’s safety.
The provider had audit processes in place to assess the quality of service provided. However, the audit processes did not act on an incident of aggression, or determine that improvements with record keeping were required.
The staff had received medicine training and their competence had been assessed. Medicines were given to people as they had been prescribed.
Staff were provided in sufficient numbers to meet people’s needs.
The recruitment processes the provider followed would not always ensure that only suitable staff were employed.
Staff received induction training and the day to day support and guidance they needed to ensure they met people’s needs.
Staff had received or were receiving the training they needed to equip them with the knowledge to support the people in their care safely.
Staff understood the requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). This ensured that people received care in line with their best interests and would not be unlawfully restricted.
People were encouraged and enabled to make decisions about their care and to be independent as possible.
Staff supported people with their nutrition and dietary needs to prevent malnutrition and dehydration.
People received assessments and/or treatment when it was needed from a range of health care professionals which helped to prevent deterioration regarding their health and well-being.
People were offered and enabled to engage in recreational activities that they enjoyed and met their preferred needs.
Systems were in place for people and their relatives to raise their concerns or complaints.
People and staff we spoke with felt that the quality of service was good.