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Inspection carried out on 31 October 2017

During a routine inspection

The inspection took place on 31 October and 2 November 2017. The inspection was unannounced.

Holmwood Rest Home provides accommodation and personal care for up to 16 older people. There were 11 people living at the home at the time of inspection. The service is located in West Parley and is a detached dormer bungalow. The accommodation offers 14 bedrooms on the ground floor and two bedrooms on the first floor. There are two staircases to access the first floor, one with a stairlift. There is a communal lounge and dining area on the first floor. There is also a conservatory and an accessible garden.

Quality assurance measures were not always effective because they did not consistently identify gaps or trends in areas of support people received. The manager rectified gaps when we identified these, but improvements were needed to ensure that there was consistent oversight of the service.

The manager of the service did not have any external links or sources of good practice guidance. We made a recommendation about this.

Risk assessments were in place and identified the risks that people faced and provided guidance about how to manage these. Staff knew peoples individual risks well and their role in supporting people to manage these safely.

People were protected from the risk of harm by staff who understood the possible signs of abuse and how to recognise these and report any concerns. Staff were also aware of how to whistle blow if they needed to and reported that they would be confident to do so.

There were enough staff available and people did not have to wait for support. People had support and care from staff who were familiar to them. Staff were consistent in their knowledge of people’s care needs and spoke confidently about the support people needed to meet these needs.

People were supported by staff who had been recruited safely, with appropriate pre-employment checks in place.

People received their medicines as prescribed and these were securely stored. Where there were gaps in information about what medicines people needed ‘as required’, the manager addressed these immediately.

The home had good links with health professionals and regular visits and discussions meant that people were able to access appropriate healthcare input promptly when required.

People were supported by staff who had the necessary training and skills to support them. Training was provided in a number of areas the service considered essential and other learning offered was relevant to the conditions that people faced.

Staff understood and supported people to make choices about their care. People's legal rights were protected because staff knew about and used appropriate legislation. The manager was in the process of ensuring that documentation was in place for people who required decisions to be made in their best interests.

People spoke positively about the food and had choices about what they ate and drank. The kitchen were aware about people’s dietary needs and catered to people’s preferences and special diets where needed.

Staff knew people well and interactions were relaxed and caring. People were comfortable with staff and we observed people being supported in a respectful way. People were encouraged to make choices about their support and staff were able to communicate with people in ways which were meaningful to them.

People were supported by staff who respected their privacy and dignity and told us that they were encouraged to be independent.

People were supported by staff who knew their likes, dislikes and preferences. Staff told us that they communicated well staff were confident about their roles and responsibilities.

People were able to engage with a range of activities including one to one time with staff. People told us that they had enough to do at the home and enjoyed the activities on offer.

Relatives spoke positively about the staff and management of the home. They told us that they were always welcomed a

Inspection carried out on 23 June 2016

During a routine inspection

This unannounced inspection took place on 23 June 2016. Holmwood Rest Home provides residential care for up to 16 older people. There were 14 people living in the home at the time of our visit, some of whom had memory problems.

The owner was also the 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 was supported by a manager who was responsible for the day to day management of the home as well as on-going improvements. The registered manager told us the manager would be applying to become a registered manager of the home.

There were systems in the home for recording accidents and incidents We saw that two people had several falls over a period of four months. We checked to see what actions had been taken. Peoples risk assessments had been updated and one person s risk of falls was increased in one month from a low risk of falls to moderate risk. There had not been amendments to the persons care plan to reflect the increase in risk. The manager told us they had discussed the person’s falls with a healthcare professional. There was no clear follow up in the persons care records. Therefore it was not clear that all possible measures were taken to minimise the risk of the person coming to harm as a result of a fall.

One person needed to live in the home to be cared for safely and they did not have the mental capacity to consent to this. A Deprivation of Liberty Safeguard (DoLs) had not been applied for. The management team did not fully understand when an application should be submitted and therefore were not working within the requirements of the Deprivation of Liberty Safeguards. This meant people were at risk of having their liberty restricted unlawfully. The manager completed the DoLs application during our inspection and told us they would review all people living in the home.

Medicines were stored and administered appropriately, the Medicine Administration Record (MAR) were stored in a ring binder and several sheets had come loose. They fell out when we picked the folder up which meant there was a risk of either losing a MAR or mixing them up.

There was a relaxed informal atmosphere in the home. The management team were visible and accessible and staff told us they were supportive. People and their relatives were positive about the staff and we saw staff were kind and considerate to people.

Food was freshly prepared in the home and we saw the food was served hot. People told us the food was very good.

People had access to healthcare when they needed it and the manager told us they had weekly support from GP’s. We saw people had appointments with a range of healthcare professionals.

People were asked to give feedback on the home in a survey. Responses were generally positive and comments received were acted upon.

Staff told us they had enough training and support to carry out their jobs. There were systems in place to provide staff with regular supervision.

People were offered a choice to join in an afternoon activity. Some people were supported to maintain independent activities such as going to the shop.

Inspection carried out on 12 May 2014

During a routine inspection

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service and staff told us, what we observed and the documents and records we looked at.

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

This is a summary of what we found:

Is the service safe?

People were treated with respect by the staff, their dignity upheld and their independence promoted.

CQC monitors the operation of Deprivation of Liberty Safeguards, which applies to care homes. While no applications had needed to be submitted we found that the registered manager was fully aware of the requirements. We saw that where risk assessments were carried out consideration was given to the least restrictive way to minimise risk. Staff had received relevant training in the Mental Capacity Act.

People were supported to be independent. Risk factors were identified, analysed and measures put in place to minimise the risk of harm.

Medication was managed safely and administered by competent staff.

Is the service effective?

People told us they were well cared for and their needs were met. From speaking with staff and observing how they supported people it was clear that they knew people well and understood their needs.

Care plans were individualised and contained guidance that enabled staff to provide effective and consistent care. Two care staff gave us examples of how they supported people to make choices in a way that was appropriate for them.

We saw that people were supported to pursue their own activities and interests. Risk was identified and analysed, and clear guidelines put in place to minimise the risk of harm.

People were cared for by staff who were trained and well supported to enable them to meet the needs of the people living at Holmwood Rest Home. We spoke with all three care staff on duty, the cleaner and the cook all of whom had received appropriate training. The records showed that new staff received a thorough induction in line with the sector standards.

The quality assurance systems in place meant that the provider was able to monitor the effectiveness of the service provided.

Is the service caring?

People were cared for by staff who were caring and attentive. People told us they were able to do what they wanted to do when they wanted. We saw that care staff supported people in way that was unhurried. One person said �Can I praise it to the hilt? The staff are so kind�. Another person who had lived at the home for a short time also told us �the staff are kind.�

People were safe and their care and welfare needs met because there were effective systems in place to ensure staff were competent to do their jobs.

Is the service responsive?

Individual needs were assessed before people moved into the home. Care plans and associated documentation showed that individual preferences and interests were recorded. We saw that staff checked with people how they would like support to be given, and that they were sensitive to people�s changing needs.

We spoke with a visiting nurse who told us that the staff worked closely with the community nursing team to promote and maintain people�s health.

Regular audits were completed, for example for medicines. We saw the results of a survey of the views of people using the service about the quality of care provided, which were positive.

Is the service well-led?

There was a clear management structure in place. The provider was registered as manager and was present during the inspection. They are referred to in this report as the registered manager. In addition there was a manager who was taking over some of the day to day operation of the home, referred to in this report as the manager. The manager was on a day off at the time of the inspection and we observed that the staff understood their roles. The registered manager and the manager had clearly defined areas of responsibility. For example, the registered manager dealt with ordering medicines and supervising staff and the manager reviewed care plans and carried out audits.

Inspection carried out on 7 November 2013

During an inspection looking at part of the service

We found that action had been taken to ensure that risk assessments were specific about how risks to people should be reduced. Staff were aware of risks and the information had been reviewed when changes had happened.

Staff only started work in the home after all appropriate recruitment checks had been completed. The manager told us they took people's safety very seriously.

Inspection carried out on 29 July 2013

During a routine inspection

Staff listened to people. When people requested a drink, staff acted quickly to meet their request. One person told us that staff always had time to stop and chat. Another person told us, "This is our home and staff respect that."

People we spoke with told us that staff knew their personal preferences and provided care the way they wanted. For example, one person told us " staff know me really well."

We looked at the risk assessments for five people. We found that risk assessments were not completed well. This meant that people could not be sure their welfare was protected as staff did not have clear information.

All medicines we looked at that were not in a blister pack were dated when they were opened. One person told us, "Staff always make sure I have my medicine when I need it."

Recruitment practice had not ensured all checks were carried out before staff worked in the home.

There had been progress in ensuring all staff received the training they needed to meet people's needs.

Inspection carried out on 31 December 2012 and 2 January 2013

During an inspection looking at part of the service

People who lived in the home spoke highly of the staff who supported them. They told us that staff were kind, caring, friendly and suitable for their role. They told us that staff understood their needs, were aware of their individual preferences and treated them well. People also told us they had confidence in staff to take the right action if they were unwell. One person commented, "They give me great help, they understand how I like things done" while another person said, "I have no complaints whatsoever...they are all excellent."

People told us there were enough staff to provide their care and keep the home clean. They told us that the employment of dedicated cleaning staff had improved staffing in the home and ensured that care staff had enough time to provide their care and spend time with them. People told us that new staff were supported by more experienced staff to ensure they had time to learn about people's needs and how to meet them.

Although the feedback we received from people who lived in the home and their relatives was very positive, there were some shortfalls in the home's recruitment procedures. This meant that not all the pre-employment checks required by law had been completed by the home before some care workers had started work. Training arrangements did not ensure that each care worker received all the training they needed in a timely way or had their competency assessed.

Inspection carried out on 1 October 2012

During an inspection looking at part of the service

We visited on 1 October 2012 to check the provider�s compliance with regulations about planning people�s care, maintaining a clean environment and monitoring the quality of care that people experienced. This was because we found shortfalls when we visited in July and August 2012 and told the provider they must take action to improve.

We found the home was kept clean. There were designated staff hours for cleaning. A newly appointed cleaner was about to start work in the home. Cleaning tasks were planned through the day and week. The manager monitored the quality of cleaning.

The provider had resumed reviewing care plans monthly. This meant people�s changing needs were recognised and adjustments in how their care was planned were made in a timely way. Short term care plans were put in place for temporary needs, such as a period of illness. If a person could display behaviours that required some form of special care or management, this was recognised in a care plan for that purpose.

The provider recognised that when they previously transferred some responsibilities to a manager, this had not been well managed. They were using learning from past experience in the imminent appointment of a new manager.

We also looked at how the service kept records. These showed evidence of being reviewed and updated and were made available as required. People who lived in the home gave examples of how they were involved in changes to how their care was organised or recorded.

Inspection carried out on 12 July and 14 August 2012

During an inspection in response to concerns

We visited Holmwood Rest Home on 12 July 2012. We spoke with three people who lived in the home. They told us it was kept clean. They told us staff regularly dusted and vacuumed their rooms and the communal rooms. We saw evidence that bedrooms and communal areas were kept free of dust. However, when we toured the home, we found that high level cleaning had been neglected. One person was remaining in bed by choice. There were cobwebs on the ceiling above their pillow.

All bedrooms in the home had en suite toilets. In these en suite facilities we found poor levels of cleaning. Toilets and toilet seats were not clean and we found sticky flooring and stained walls. Some floor coverings were unsuitable for use in these locations and others were not sealed at the edges. These aspects of the environment showed that people were not protected against risk of infection.

The kitchen appeared clean. However, one area of the kitchen was used for storage of documentation, which staff needed frequent access to. This meant the kitchen had extra people going in and out, from doing other tasks in other parts of the home, causing posible infection control risks.

People who lived in the home told us staff came when they needed them. One of the people had been served lunch in their bedroom. They told us their food was hot and staff were punctual in serving and collecting their tray. During the day we saw staff conversing with people when they carried out caring tasks. During the afternoon a regular visiting music and movement facilitator involved several of the people in the home in conversation and exercise.

People told us they knew the registered manager well and that they were sometimes asked if they were satisfied with how the home met their needs. They told us they enjoyed a variety of meals and they liked the environment. However, we found that the quality of the service was not being monitored in a consistent way.

We spoke with four members of staff, during our visit and by telephone. Staff had different experiences of training. At times their availability to the people living in the home was restricted by the necessity to undertake cleaning and cooking. In the case of cleaning, the evidence was that the time made available was insufficient to maintain cleanliness at a safe level.

We made a second visit to the home on 14 August 2012 as we received information of concern in relation to care planning, meals provision and arrrangements for handling medicines. We spoke with eight people who lived in the home. People told us they liked the menu and the way meals were provided in the home. Medicines were being administered safely. We found that care planning was not based on the most up to date information that the home had about people's changing needs.

Reports under our old system of regulation (including those from before CQC was created)