Holly House Residential Care Home

Social Care Org · East

Overall Rating
Requires Improvement Last inspected 11 September 2015
Domain Ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Requires Improvement
Well-led
Inadequate

View Full CQC Report

8 must-do actions
3 should-do actions

Must-Do Actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The provider must ensure there are sufficient staff to support people in a way that ensures their continued safety.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The lack of sufficient staff meant that people were not always supported in a way that ensured their continued safety.
Must Do
Safe
The provider must ensure medicines are managed safely, including securing medicines and ensuring timely detection and response to incidents.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010
Medicines were not always managed safely. A person accessed the medicines trolley and consumed tablets because the medicines were not secured. The incident went undetected for a period, leading to an unacceptable delay in seeking professional help.
Must Do
Safe
The provider must ensure that plans for managing risks to people's health and well-being are addressed and clearly state how risks are managed or mitigated.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010
Risks to people’s health and well-being were identified and detailed in people’s care plans. However the risk assessments did not say how risks were managed or mitigated.
Must Do
Safe
The provider must have adequate arrangements in place to respond appropriately to people’s changing needs and emergencies.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The provider did not have adequate arrangements in place to respond appropriately to people’s changing needs.
Must Do
Effective
The provider must ensure people receive appropriate support to eat and drink sufficient amounts to maintain their health and well-being, including effective monitoring of nutritional needs, provision of adequate and in-date food, and clear instructions for staff.
Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
People did not receive the appropriate support to ensure they were able to eat and drink sufficient amounts to maintain their health and well-being.
Must Do
Well-led
The provider must ensure effective governance arrangements are in place, including clear roles and responsibilities, effective communication, robust recruitment and contingency planning, and comprehensive quality monitoring and auditing.
Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014
There were poor governance arrangements in place.
Must Do
Well-led
The provider must inform the Care Quality Commission (CQC) of important events that happen in the service in a timely way.
Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014
The provider had not informed the CQC of significant events in a timely way. For example we were not informed that the home would be closed down for five days during a planned holiday.
Must Do
Well-led
The provider must ensure that staffing rotas accurately demonstrate staffing numbers, reflect all shifts worked, and reconcile with payroll records and actual hours worked.
Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The rotas did not demonstrate staffing numbers and records were inconsistent for example rotas had gaps, so staff who were asked to cover shifts at short notice were not detailed on the rotas. Also the rotas did not demonstrate whether people were off work, on holiday or off sick. The …

Should-Do Actions (3)

Recommended improvements to enhance service quality.

Should Do
Caring
The provider should ensure people are always supported in a way that maintained their dignity, especially with expressing their sexuality, and that people have choices about how their care and support is provided.
Should Do
Responsive
The provider should ensure people's care is responsive to their needs, including providing planned one-to-one support, ensuring care plans are up-to-date and accurately reflect current needs, and offering a range of activities that reflect people's choices.
Should Do
Responsive
The provider should ensure the complaints system is effective and that people feel comfortable complaining and that their concerns are listened to and dealt with.
Location Details
CQC ID: 1-108962966
Local Authority: Hertfordshire
Region: East
Inspection Report
Type: Comprehensive inspection
Date: 11 September 2015
Rating: Requires improvement
Actions: 8 must-do , 3 should-do
AI-extracted 17 Feb 2026