Holly Hall House

Updated 11 March 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. This was a targeted inspection looking at the infection prevention and control measures the provider had in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

The inspection was carried out by one inspector. The inspection took place on 17 February 2022 and was announced. We gave the service 24 hours’ notice of the inspection.

Updated 11 March 2022

This unannounced inspection took place on 17 January 2019. Our last inspection of the service took place on 14 February 2017. The provider was rated overall as `Requires Improvement`. We found that improvements were required with the way medicines were managed, the accuracy of medication records and the effectiveness of quality assurance audits. At this inspection we found that these improvements had been made.

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.