Holly Lodge Residential Home

Holly Lodge is a residential care home providing personal and nursing care to 20 older people at the time of the inspection. The service provides care and support to older adults and people living with dementia as well as other health conditions. The service can support up to 22 people.

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

The provider and registered manager did not always have sufficient oversight of the service. Appropriate action had not always been taken when concerns had been raised, and records did not always reflect the changing needs of people. Audits were not always effective at identifying areas for improvement.

People could be assured the staff who supported them were recruited in a safe way.

People’s prescribed medicines were administered and managed well.

Infection prevention and control processes were managed in a safe way.

Rating at last inspection

The last rating for this service was good (published 29 January 2020).

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about safeguarding issues, how allegations were managed and unsafe medicines administration. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with safeguarding issues and how allegations were managed, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

At this inspection, we identified a breach of regulation in relation to the management and leadership associated with the promotion of a positive culture, accurate record keeping, the safe management of individual risk and learning lessons from incidents and concerns.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Holly Lodge Residential Home is a care home providing personal care. The service is registered to provide support to up to 22 people. At the time of the inspection 21 people were living there. Not everyone who lived at the service received personal care. This is help with tasks related to personal hygiene and eating.

The accommodation was provided in one adapted building. People living at the service were older and many lived with dementia.

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

The people and relatives we spoke with all told us they were happy with the service. Comments included, “The staff are marvellous.” And, “The staff are kind to me and to my friends.” Health and social care professionals were also positive about the staff and the safety of the service.

Care plans had been reviewed and included the information staff needed to support people to remain safe. People received their medicines as prescribed and were protected from the risk of infection spreading. Staff knew how to keep people safe from abuse. If there were incidents or accidents staff reported these and they were investigated, and action was taken as needed.

There was enough staff to support people safely. Staff were not rushed and had time to spend talking to people and provide emotional comfort. Staff were recruited safely and had the skills and knowledge to provide support to people. There were regular staff meetings and supervisions and appraisals took place to discuss staff practice.

People were supported to maintain their health. People were supported to eat well and drink enough. The feedback on the food at the service was positive. If people became unwell they were supported to access health care services such as the GP.

When people moved to the service, their needs were assessed. These assessments were used to develop person centred care plans which included information on people’s needs and preferences. People’s equality needs such as religious or cultural needs were met. End of life care was discussed with people and their wishes and preferences were recorded. People were involved in planning their own care and their preferences and choices were respected.

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. Staff supported people to make day to day choices.

The service was lively, and people enjoyed the activities which were offered. Relatives told us that they were welcome at the service and had a good relationship with staff. There was a complaints system in place if people or their relatives were unhappy about anything at the service. People had opportunities to feedback about the service through written surveys and residents’ and relatives’ meetings.

There was a positive atmosphere at the service and staff were happy in their roles. Staff were well supported and supervised appropriately. Checks of the service quality were undertaken and issues were acted upon where identified. The provider and registered manager understood their legal responsibility to report significant events to CQC and did so.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Requires Improvement (report published on 28 March 2019).

Following the last inspection, the provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The service met the characteristics of Good in some areas and Requires Improvement in other areas. The overall rating is Requires Improvement.

People’s experience of using this service:

We found improvements were needed in three main areas. Management plans to protect people from identified risk were not always in place; Fire safety procedures were not robust; Care plans did not always reflect people’s complex needs; Quality monitoring was not sufficient to identify and action improvements needed. The living environment was not adapted to suit the needs of some people. We have made a recommendation about this. Some people told us there was not enough in the way of activities in the service and our observations confirmed this. We have made a recommendation about this.

People were very happy living at Holly Lodge Residential Home and were cared for by staff who were content in their work and knew people well. Staff were well trained and supported by a provider and registered manager who were approachable and supported their well-being to enable them to provide good quality care.

People were supported to make everyday choices and decisions about their care and support which created a relationship of trust.

A person centred approach was evident where people were assisted to maintain their independence.

More information is in the detailed findings below.

Rating at last inspection: Good (Report published 31 January 2017)

Why we inspected: This was a planned inspection based on the previous rating.

Follow up: We will continue to monitor this service and plan to inspect in line with our inspection schedule for those services rated Requires Improvement.

The home provided residential accommodation and personal care for older people living with dementia. The accommodation was provided for up to 22 people over three floors in the main building and in a ground floor single storey extension. In the main building a stair lift was provided for people to move between floors and an external fire escape had been installed for use in emergencies. There were 20 people living in the home when we inspected.

There was a registered manager employed at the home. 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 home is run. The registered manager was not present during the inspection as they were on maternity leave. However, information we looked at showed how the registered manager led the service and the owners who were the providers of the home assisted with the inspection process.

At the previous inspection on 12 November 2015, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The two breaches were in relation to the safe management of medicines and the lack of effective systems to assess and monitor the quality and safety of the service provided. The provider sent us an action plan telling us what steps they would be taking to remedy the breaches in Regulations we had identified. At this inspection we checked they had implemented the changes.

At the previous inspection on 12 November 2015 we also made five recommendations to assist the provider to make improvements to the service provided. These recommendations were in relation to how staff were deployed at key times, choices around food, the supervision of staff, suitable activities and the review of policies and procedures.

At this inspection we found that the provider had taken steps to meet the regulations breached at our previous inspection and made changes in response to the recommendations in our inspection report following our inspection of 12 November 2015. However, at this inspection we have made several further recommendations.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Restrictions imposed on people were only considered after their ability to make individual decisions had been assessed as required under the Mental Capacity Act (2005) Code of Practice. The registered manager understood when an application should be made. Decisions people made about their care or medical treatment were dealt with lawfully and fully recorded.

The provider had updated the medicines policies and a procedures in line with published guidance to ensure the safe administration of medicines. Staff followed these policies and had been trained to administer medicines safely.

The provider had reviewed the activities available and continued to introduce a wider range of activities for people both in the home and outside of the home. An activity planner displayed enabled people to see what activities they could participate in.

We observed people had access to a variety of foods and a menu was displayed to enable people to decide what they may like. At lunch time people were given a verbal choice of foods and were shown the foods if needed to assist them to make a decision. People from different cultural backgrounds were provided with food in line with their cultural choices.

The quality audit systems had been reviewed within the home to make them more effective. The risk in the home was assessed and the steps to be taken to minimise them were understood by staff. All of the policies we viewed had been updated to comply with current legislation.

The home was cleaned to a high standard following a cleaning schedule which included a deep cleaning routine; there were no unpleasant odours in the home. The provider had used a recognised contractor to test the homes water systems for potential infections. However we noted that a risk assessment and management plan was not in place covering Legionella. We have made a recommendation about this.

People and their relatives described a home that was welcoming and friendly. Staff were upbeat and happily provided friendly compassionate care and support. People were encouraged to get involved in how their care was planned and delivered. The care planning systems in the home took account of people’s independence and rights to make choices. Staff understood how to resect people’s privacy and dignity. However, we noted that in one case a member of staff had not considered this when cutting people’s nails in the lounge. We have made a recommendation about this.

New staff received an induction and training was on going and planned in advance. New systems had been implemented for supervisions and appraisals. Records showed and staff confirmed the new system was in use.

We observed people who looked relaxed and safe. Relatives told us that their loved ones were well cared for and safe in the home. Staff had received training about protecting people from abuse. Staff understood their responsibilities to protect people from harm. The management team had access to and understood the safeguarding policies of the local authority and followed the safeguarding processes.

Recruitment policies were in place. Safe recruitment practices had been followed before staff started working in the home. The provider ensured that they employed enough staff to meet people’s assessed needs. Staffing levels were kept under constant review as people’s needs changed.

People had access to GPs and their health and wellbeing was supported by prompt referrals and access to medical care if they became unwell and additional care from community nursing teams.

The provider, registered manager and care staff used their experience and knowledge of people’s needs to assess how they planned people’s care to maintain their safety, health and wellbeing. Risks were assessed and management plans implemented by staff to protect people from harm.

Incidents and accidents were recorded and checked by the registered manager to see what steps could be taken to prevent these happening again.

The provider and management team ensured that they had planned for foreseeable emergencies, so that should they happen people’s care needs would continue to be met. The premises and equipment were maintained to keep people safe.

The provider and registered manager had involved people and relatives where appropriate in planning their care by assessing their needs and asking them about their lives and histories. This helped staff deliver care to people as individuals. After people moved into the home they were asked on a regular basis about their experiences of the care they received. Each person had a key worker and we observed that staff knew people well.

The provider and staff understood the challenges people faced from their dementia. They demonstrated a commitment to work with other health and social care professionals and do all they could to work through some of the issues people faced. Staff encouraged and supported people to maintain their health by ensuring people had enough to eat and drink.

If people complained they were listened to. The provider and the registered manager made changes or suggested solutions that people were happy with. The actions taken were fed back to people.

The registered manager and other senior managers provided good leadership. The home was well led by an experienced registered manager. The registered manager had wider management support within the home as the providers were based at the home and supported the registered manager. Staff and relatives told us that managers were approachable and listened to their views.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service and a visiting relative, the staff and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Following on from the previous inspection on 8 May 2014, the provider had made sure risk assessments had been undertaken to identify risks. They gave detailed instructions for staff to ensure people remained safe. The care records were detailed and staff had a good understanding of the needs of people who lived in the home. For example, when we spoke with staff they were able to describe the individual care that people needed and what steps staff needed to take to minimise any identified risks.

We saw that the manager had prepared an emergency evacuation plan (PEEP) for each person who lived in the home. This meant staff would be able to respond appropriately if they needed to evacuate the home.

Is the service caring?

People who lived in Holly Lodge were supported by kind and attentive staff. We observed staff interacting with people who used the service and noted how staff continued to provide encouragement, reassurance and practical help. We saw staff helped people with their care and support and heard them offering choices to people who lived at the home.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service and a visiting relative, the staff and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We evidenced the service used the Deprivation of Liberty Safeguards (DoLS) to protect the rights of people who lived at the home. We spoke with the manager and senior staff who demonstrated their knowledge of the procedures to follow. We saw evidence that an application had been submitted following their concerns that a person's liberty was being limited to keep them safe. We found that people's mental capacity was assessed and best interest meetings were held according to legal requirements. We had confirmation that all staff had been trained in DoLS, Mental Capacity Act 2005 and Safeguarding of Vulnerable Adults. We found some risk assessments had been undertaken, however risks assessments had not been undertaken for all identified risks. We also found that following the risk assessment there were not always detailed instructions available for staff to ensure people remained safe. The care records were not all up to date, detailed enough in some cases and we found that one incident recorded in the daily records had not been reported to the relevant authorities. When we spoke to staff they were able to describe the individual care that people needed and what they did to minimise risks.

Is the service effective?

People and a relative told us they were satisfied with the quality of care that had been delivered. One relative we spoke with said, 'I am happy with the care provided here'. We saw that the delivery of care was in line with people's wishes, and that people were treated with dignity and respect. Staff that we spoke with had a good understanding of people's individual needs, likes and dislikes. However, we found that the staff had not all received training to meet the needs of people who lived at the home. For example, we found that few staff had received training courses in dementia, diabetes, stroke and palliative care.

Is the service caring?

We found that people who lived in Holly Lodge were supported by kind and attentive staff. We observed staff interacting with people who used the service and noted how staff provided encouragement, reassurance and practical help. We saw staff helped people with their care and support, at mealtimes and during activities with patience and kindness. A person who used the service told us, 'I am well looked after, staff do check on me regularly'. A visiting family told us 'My sister is well looked after here' We also observed that people who lived in the home looked well cared for and staff offered choices and encourage people to do what they could for themselves.

Is the service responsive?

The manager explained that people's needs had been assessed before they moved into the home and their support plans were reviewed regularly to reflect any change in their needs. However, we did not see that the change had been recorded in the care plan. We saw that people's records included people's history, wishes and preferences and personal information. People and/or their representatives were involved with care plans however this was not always recorded. Families were kept informed of any changes. One person who lived in the home told us 'They always let my daughter know when I'm not well or anything'. We also saw that when people were not well that the home contacted for example the person's doctor or the district nurse.

Is the service well-led?

We found that there were policies and procedures that addressed aspects of the service in place; however these had not been regularly updated. We found for example that the policy and procedures for Infection control were not up to date with the most recent legislation. The registered manager had not operated a comprehensive system of quality assurance or completed audits to identify any short falls in the management of the service.

People and their relatives or representatives were consulted about how the service was run and annual survey questionnaires were sent and analysed. Staff told us they were able and encouraged to express their views and concerns they may have and were listened to. Some incidents and accidents were appropriately recorded and action taken to reduce identified risks. However, not all staff were aware of who to report incidents to. Staff practice was regularly observed and supervised by the senior staff to identify whether additional training or support were needed.

We looked at people's care records, spoke with staff and observed the interaction between staff and people who lived in the home. People who lived in the home have dementia and therefore communication is often non-verbal. Staff were seen interacting with people appropriately and were able to tell us about people's individual needs.

We found people's needs had been assessed; care plans cross referenced and had been discussed with people's relatives. The care plans gave staff instructions on how to care for people and meet their needs. However, we did find that there was a lack of guidance for staff to follow for those people who did not go to bed at night on a regular basis.

We looked at daily records written by staff, we found some of these had been written in advance detailing care that had not happened. This meant people may be at risk of not receiving the care that had been recorded or agreed.

Other records such as monitoring charts had also not been completed accurately.

We looked at the equipment required and used with in the home. The provider confirmed that all staff had received moving and handling training and that staff were not permitted to use hoists for example if they had not been instructed on how to use it. Hoists were also found to have been serviced in a timely manner.

During the day we talked with 7 people who lived in the home; two relatives; and four staff as well as the manager. People spoke highly of the care given and said that the home was 'very friendly'. One relative said 'It is calm here and the staff are so good, you can't fault it.' One of the people who lived in the home said "Everyone is always so kind and helpful. I am very happy with everything." Staff spoke positively about their roles, and we saw that they worked well as a team.

We found that the staff ensured that people's on-going health needs were met, and contacted other health professionals as appropriate.

We inspected food and nutritional processes, and found that people were provided with a limited choice at meal times however people told us they enjoyed the meals.

We had received some concerns about the availability of lifting and other equipment in the home; however during our visit we found the necessary equipment was available.

We found that the home had reliable staff recruitment processes in place.

We found that monitoring is in place to ensure the quality of the care and support provision; however this was not always being documented.

Relatives of one person said 'They are kind to everyone, and show great compassion. It's been wonderful, I'd recommend it'.

Staff demonstrated how well they knew the people living at the home and that they understood their diverse and sometimes complex needs.

Staff received the training and support they needed to carry out their roles.

We found that there were systems in place to monitor the quality of the service and that people living at the home were listened to and involved in the running of the service.