Holly Lodge

Holly Lodge is a care home providing personal and nursing care to 16 people with a learning disability at the time of the inspection. The service can support up to 18 people.

Holly Lodge accommodates people across three separate wings, each of which has separate adapted facilities. The building is connected by one large communal room shared by all three wings. At the time of the inspection the communal room was not in use due to coronavirus restrictions.

The large outside space was being developed to include accessible pathways, raised flower beds, vegetable plots and socialising areas. The adjoining land had been re-developed into a new housing area and the signage to Holly Lodge was being changed to fit in with the new street address signs.

Holly Lodge was built and registered with CQC before our guidance Right support, right care, right culture and NICE guidelines were implemented. This means the service is larger than the current guidance recommends.

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

Not all care plans, risk assessments and service documentation were up to date or reviewed according to the provider’s timescales. Staff training records needed to be updated and recorded accurately onto one system. Some records had gaps and elements were missing from mental capacity documentation. The management team were aware of these shortfalls and had an action plan in place to make improvements. We found no evidence that people had been harmed as a result of these shortfalls.

People received a kind and caring service. Staff were committed to delivering a good standard of care. Staff were proud to work at Holly Lodge and provide compassionate and respectful care to people at the end of their lives. The management team led by example.

People had their individual risks assessed. People received their medicines as prescribed. Staff understood their responsibilities to protect people from harm and abuse.

Staff were knowledgeable about people’s choices and preferred way of being supported. Care plans were person centred and contained guidance for staff on how best to meet people’s needs.

People were protected from the risk of infection. Staff had access to plentiful supplies of PPE. The service worked very hard throughout the pandemic to keep people safe from COVID-19 and there had been only one isolated incidence of COVID-19 infection.

People, their relatives and professionals who worked with staff were complimentary about the service and the support provided for people. People told us they were happy living at Holly Lodge.

The management team had good working relationships with health and social care colleagues and delivered good outcomes for people.

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.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right support:

• The service was larger than the current guidance recommends. However, each wing of Holly Lodge was adapted and operated independently of the others with their own communal area. A larger communal space joining each area at the centre of the home was not used currently due to pandemic restrictions. We did not see any evidence that people were negatively impacted by this. The home was accessible but in need of updating, re-design and re-decoration, this work was in progress.

Right care:

• The support provided by staff was kind and caring. Care plans reflected their person-centred approach. People received compassionate and respectful care towards and during the end of their lives.

Right culture:

• The ethos, values, attitudes and behaviours of the provider and management team fed down to the nursing and support staff. Staff were proud to work at Holly Lodge and provide people with a good standard of care. People told us they were happy.

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 (published 5 November 2019) and there were multiple breaches of regulation. 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 not enough improvement had been made and the provider was still in breach of regulation 17 Good governance.

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led section of this full report.

You can see what action we have asked the provider to take at the end of this full report.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe, effective and well-led sections of this full report.

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

We have identified a breach of regulation in relation to record keeping and administration at this inspection.

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 for the provider to understand what they will do to improve the standards of accurate and contemporaneous record keeping. 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 provides accommodation with nursing and personal care for people with a learning disability and/or associated health needs. Holly Lodge accommodates people in three separate units each with its own facilities. They are joined into one building by a large activity room, which all three units shared. The service is all on the ground floor with private gardens. At the time of our inspection there were 15 people living at the service.

The service has not been fully developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence.

The service was larger than current best practice guidance or within principles for the number of people living in one property. It was bigger than most domestic style properties as 18 people were accommodated. The size and location of the service having a negative impact on people was not mitigated by the building design. The service was located away from other properties set in its own grounds. This meant the service was geographically isolated from the village of Pewsey. The signage identified Holly Lodge as a care home although staff were discouraged from wearing uniform that suggested they were care staff when accompanying people.

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

The service didn’t always consistently apply the principles and values of Registering the Right Support and other best practice guidance. People did not consistently receive person-centred care. Some interactions observed demonstrated use of inappropriate language and a lack of awareness of people’s privacy and dignity. We were not confident people were given choice in all aspects of their life, for example, we observed staff giving people meals without offering them choice.

People’s medicines were not always managed safely and not all staff had their competence to administer medicines checked. Risks were not always managed safely as systems were not in place to make sure all risks were identified, assessed and management plans put in place. For example, risks of using bed rails had not been assessed with safe management plans in place. Staff took immediate action to make sure bed rails were safe during our inspection. There were sufficient numbers of staff on duty. The service was clean and smelt fresh.

Staff had not always had the training they needed to care for people effectively. There were issues with staff accessing training which the management team were aware of.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. The policies and systems in the service did not support this practice. The service could not demonstrate that when decisions were being made for people they were the least restrictive option.

People had access to healthcare when needed and staff worked together and with other professionals. People had support to eat and drink and mealtimes seen were unhurried and a social occasion. However, choices of meals were not provided on both days of the inspection.

People did not always have an up to date care plan and monitoring information for staff to follow. The service was in the process of transferring records to an electronic system which meant there were many plans that needed updating. Monitoring records were not completed accurately and in full to record care and support provided. Some guidance provided was detailed and had been updated. People had the opportunity to record their end of life wishes and plan for the care they wanted.

We were not notified of all reportable incidents. Quality monitoring was not effective in identifying all the improvement needed. Action plans were not in place where improvement had been identified. This meant we were not able to see if actions needed had been carried out. Complaints were managed, however the complaints policy had incorrect information. The provider told us they would update this policy.

Despite the shortfalls we had found at this service people and their relatives told us they were happy with the care provided. The service had a registered manager who was established and experienced. One relative told us the registered manager was, “approachable, natural, professional, available and hands on”. Some people had experienced good outcomes and made improvements in areas such as wellbeing. People and their relatives told us staff were caring and knew people well. We observed some positive interactions that showed staff had a caring approach and knew how to adapt their approach for individuals.

We have found three breaches of Regulations.

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

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/ or autism. Thematic reviews look in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drivers of improvement.

As part of thematic review, we carried out a survey with the registered manager at this inspection. This considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation ) when supporting people.

The service used some restrictive intervention practices as a last resort, in line with positive behaviour support principles.

Rating at last inspection –

The last rating for this service was Good (report published 26 April 2017).

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.

We will request an action plan for 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.

At the last inspection on 01 September 2015 the service was rated good overall with one requires improvement in the Responsive domain. This domain had two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that the registered person had not maintained accurate records in respect of each person, including a record of the care and treatment provided. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that the registered person had not designed care and treatment to reflect people’s preferences and ensure that support plans reflected people’s care and support needs because accurate and appropriate records were not maintained. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook a full comprehensive inspection on 27 and 28 March 2017. After the previous inspection the provider wrote to us with an action plan of improvements that would be made to meet the legal requirements in relation to the law. We found on this inspection the provider had taken all the steps to make the necessary improvements.

At this inspection we found the service had made all the necessary improvements and remained Good. We have improved the rating for the key question ‘Is the service responsive’ from ‘requires improvement’ to ‘good’.

A registered manager was employed by the service and was present throughout our inspection. 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.

People’s care was provided with kindness and compassion. Staff respected people’s privacy and dignity. We observed that people looked relaxed and comfortable in the company of staff and did not hesitate to seek assistance when required. Staff had a good understanding of people’s needs, abilities and preferences.

People were protected against the risks of potential harm or abuse. Staff knew how to keep people safe from the risk of abuse or harm whilst still supporting them to remain independent. Risks to people had been identified and guidance was in place to support staff to minimise these risks. There were sufficient staff deployed to keep people safe and meet their needs. Appropriate recruitment practices were followed to ensure that staff employed at the service were suitable to support people safely.

People were supported to eat a balanced diet. Where required people had access to specialist diets. Staff supported people to access appropriate healthcare services they needed to maintain good health.

There were arrangements in place to ensure people’s medicines were managed and administered safely and as prescribed.

Care plans were in place detailing how people wished to be supported with their care. The care plans had been completed by those people who knew the person well and where possible people using the service.

The registered manager and staff had knowledge of the Mental Capacity Act 2005. The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS).

There were quality assurance systems in place which enabled the provider and registered manager to assess, monitor and improve the quality and safety of the service people received. Procedures were in place for the registered manager to monitor, investigate and respond to complaints in a timely manner.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found '

Is the service safe?

People who lived at Holly Lodge were unable to tell us what they thought about the support and care provided. Relatives we spoke with said that they had every confidence in the care provided. One person told us 'I couldn't wish for better care. I am more them 100% satisfied.'

Care plans provided guidance for staff on how to meet people's needs in a way which minimised the risk for the individual. Some information we reviewed during our inspection did not always support the person to receive the correct care and treatment.

People received their medicines as prescribed. However during our inspection we saw that one person's 'as required' medicine had expired and a replacement was not available. Guidance on when to administer 'as required' medicine was also unclear.

People were safe because care staff knew what to do when safeguarding concerns arose. Staff had received appropriate training and followed policies and procedures. This ensured that staff were able to identify unsafe practices and take appropriate action to resolve them.

Recruitment practices were safe and thorough.

There was a member of senior staff available on-call at all times in case of emergencies.

Senior staff organised the rotas, taking in to account people's care needs to ensure correct decisions were made about the numbers, qualifications, skills and experience required. There was a qualified nurse available on every shift. This helped to ensure that people's medical needs along with their social needs were being met.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly therefore not putting people at unnecessary risk.

Is the service effective?

Care plans reflected people's current individual's choices and preferences.

People's care and welfare needs were assessed. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

People had access to appropriate space where they could either spend time together or be alone.

The home had access to an advocacy service if people needed it. This meant that when required people could access additional support.

Staff received effective support, induction, supervision and training.

Is the service caring?

We observed that people were supported by caring staff. We saw that staff showed concern for people's well-being.

Care staff we spoke with confirmed that they were responsible for reading people's care plans and for ensuring that they were up to date with any changes. Care plans we reviewed reflected people's needs, preferences and diversity. However daily notes we reviewed did not always identify the support offered to the person during the course of the day.

People who lived at Holly Lodge were unable to tell us what they thought about the support and care provided. Relatives we spoke told us they were very happy with the care provided. One relative said 'I am very, very happy with the care X receives.' Another person told us 'The care here is excellent.'

Is the service responsive?

The service worked well with other agencies, health professionals and family members to make sure people received consistent care. Records contained details of appointments with health professionals and any outcomes. We saw that referrals were made to the appropriate health services when people's needs changed. However some information we reviewed during our inspection did not always support the person to receive the correct care and treatment.

People regularly attended a range of activities both in and outside the service. The home had its own adapted vehicles which helped people to remain involved in their local community.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care settings. Appropriate policies and procedures were in place. Staff had received training in the Mental Capacity Act 2005 and the application of DoLS. Where the provider was unsure if services provided were a deprivation of someone's liberty we saw referrals had been made to the funding authority for clarification. One person had guidelines in place that supported staff to know the correct procedures for restraint. However two staff members we spoke with told us they had not received training in this area.

Is the service well-led?

Staff we spoke with understood and knew what was expected of them. Staff were caring and had received professional development appropriate to their role.

The service had quality assurance systems in place. Records we reviewed showed that where issues had been identified actions had been taken to resolve them.

Concerns, complaint and compliments were used as an opportunity for learning or improvement.

Policies and procedures were regularly reviewed throughout the year and were available for staff at all times.

The provider sent us an action plan which confirmed they had taken action in relation to the areas we identified.

Due to their complex disabilities, people were unable to give us detailed feedback about the care they received. In order to gain information about their wellbeing, we observed interactions and talked with staff.

During this inspection, staff told us staffing levels had increased and there were sufficient numbers of staff on duty to meet people's needs. There were now more trips out and staff were undertaking more individual work with people.

People were relaxed and looked well supported.

Each person had a detailed, comprehensive support plan which demonstrated their needs and how they were to be met. Clear management plans were in place for specific issues such as eating and drinking and where required, for people's health care conditions such as epilepsy.

Staff spoke to people in a caring and respectful manner.

People were offered a varied diet. Their nutritional and hydration needs were regularly assessed and their food and fluid intake was monitored.

The home was clean and staff were aware of their responsibilities to minimise the risk of infection.

There were clear auditing systems in place to assess and monitor the quality of service provision.

We looked at three people's care files and saw they contained information about people's choices about the care they would like to receive from the staff team. We observed staff treated people with respect when they delivered personal care.

Staff members told us they had received training in the protection of vulnerable adults. Staff were able to describe this training, which showed they understood its content. We saw they had a system to receive yearly updates to ensure they knew current information and practises.

We saw written evidence which confirmed regular staff supervision and yearly appraisals were in place.

We looked at the staff rotas and saw the staffing levels were not always sufficient to meet the needs of people who used the service. Staff told us this meant, at times, they were only able to provide "basic care" to keep people safe. They told us people's activities had "suffered" due to the lack of staff and so had their "intensive interactions" which benefited people who had limited communication.