CQC report explained · a residential care home, run by Achieve Together

Holly Tree Cottage

243 Berrow Road, Burnham-on-Sea, TA8 2JQ

Requires improvementpublished 13 August 2022, 4 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask

Safe?: Requires improvement; Staff recognised distress, but one person's plan was not always followed. Inspectors found that unplanned seclusion and physical intervention had placed the person and staff at risk.
Effective?: Requires improvement; This question was not assessed during the targeted inspection.
Caring?: Good; This question was not assessed during the targeted inspection.
Responsive?: Good; This question was not assessed during the targeted inspection.
Well-led?: Requires improvement; This question was not assessed during the targeted inspection.

The latest report, explained

What inspectors found, September 2023

Inspected but not rated; inspectors found staff recognised distress, but one person's needs could not be safely met and unplanned restrictions had been used.

This was an unannounced targeted inspection. It looked at how people experiencing emotional distress were supported, rather than the whole service. One inspector visited the home on 24 August 2023 and spoke with people, staff and managers. They also reviewed care plans, incident records, investigations and staff meeting minutes.

Staff usually recognised signs of distress and care plans explained how to respond and avoid restricting people's freedom. Plans for other people inspected were being followed and appeared effective. Staff reported incidents, managers investigated them and staff took part in reviews to learn from what happened.

However, one person's plan had not always been followed. This included a period of seclusion in their room and an unplanned physical intervention without safeguards. Inspectors found that this person's changing needs could not safely be met at the home. The provider was looking for a more suitable service and discussing interim plans.

The service was inspected but not rated because this was a targeted inspection. The previous overall rating was Requires Improvement, published on 13 August 2022, and that rating remained unchanged.

What inspectors praised

Recognising distress
Staff recognised when people were becoming emotionally distressed. Care plans gave guidance on how staff should respond.
“Staff recognised signs when people experienced emotional distress.” from the report
Support for other people
The plans inspectors checked for other people were being followed and were effective in supporting them during distress.
“Other people's plans we looked at were being followed and were effective in supporting people at times of distress.” from the report
Learning from incidents
Staff reported incidents appropriately. Managers investigated them, shared lessons and held reviews with staff after incidents.
“Staff took part in post incident reviews, after they had supported people experiencing emotional distress.” from the report

What inspectors were concerned about

One person's needs were not safely met
serious
Inspectors found that one person's current and changing needs could not safely be met at the home. The provider was looking for a more suitable service and discussing temporary plans.
“It was evident 1 person's current and changing needs, in relation to their distress, could not be safely met at Holly Tree Cottage.” from the report
Unplanned restrictions
serious
One person's plan was not always followed. Inspectors found that the person had been secluded in their room and had experienced an unplanned physical intervention without safeguards.
“Unplanned restrictions and seclusion place both the person and staff at risk.” from the report

Questions to ask them, based on this report

01What interim support plan is now in place for the person whose needs could not safely be met?
02What progress has been made in finding that person a more suitable service?
03How will you make sure each person's care and support plan is followed during distress?
04What safeguards are in place if restrictive intervention or seclusion is considered?
05Has the new manager registered with the CQC, and who is responsible for the home until that happens?

This was an unannounced targeted inspection of support for people experiencing emotional distress; it did not assess the whole Safe key question or the other four key questions, so the previous ratings remained unchanged. This explanation was written from the published report of 23 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Holly Tree Cottage

2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.

September 2023Inspected but not ratedcurrent rating
Safe: Inspected but not rated
Read what inspectors found at Holly Tree Cottage →
December 2022Inspected but not rated
Safe: Inspected but not rated
We are reading this report · the original is on cqc.org.uk
August 2022Requires improvementdown from Good
Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read this report on cqc.org.uk
February 2020Good
Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
December 2020
Registered with the Care Quality Commission on 1 December 2020.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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Canterbury, CT4

Good

Residential

Burnham-on-Sea, TA8 · 1.0 km

Good

Residential

Rated 7 years agocare home

What inspectors found, September 2023

Recognising distress

Support for other people

Learning from incidents

One person's needs were not safely met

Unplanned restrictions

Every inspection of Holly Tree Cottage

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