Holly Lodge provides accommodation with nursing and personal care for up to 18 people with a learning disability and associated health needs. The service is one of many, run by the White Horse Care Trust within Wiltshire and Swindon. At the time of our inspection 16 people were living in the home. The home has a vacant bed which was used to provide respite care. The home is divided into three different units with six bedrooms on each unit.

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

At the time of our inspection there were seventeen people living at Holly Lodge. Holly Lodge is split into three separate units. One inspector carried out this inspection.

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.

At our last inspection on 9 March 2013, we identified there were insufficient staff on duty to effectively meet people’s needs. We issued a compliance action to ensure the provider made improvements.

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.

The people who lived at Holly Lodge had a range of complex disabilities and communication needs. They were not able to tell us what they thought about the care they received, so we observed staff interactions with them. We saw the staff were kind and considerate towards the people they cared for. We observed them spend time with people massaging their hands and communicating, using signs and facial expressions.

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.

We carried out this review to check whether Holly Lodge had taken action in relation to

Outcome 14 - Supporting workers

Outcome 16 - Assessing and monitoring the quality of service provision

following an inspection on the 14th December 2011.

No action plan was received from the provider.

We found that although staff felt supported few staff had received regular formal supervision and performance appraisal.

We found that the provider had regular systems and processes in place to support the quality of its service

The people living at Holly Lodge were not able to tell us what they thought about the care they received. However we observed that they were clean and, appropriately dressed and they appeared to be content and comfortable in the company of staff that they knew.

We spoke on the telephone to relatives of people living at the home. One relative told us, “In the main I think X is comfortable and happy there. They told us that their relative was able to make only limited choices about the way they lived their lives. However, they were confident that long standing staff knew their relative well enough to make appropriate decisions for them.

Staff were described as caring and respectful but several comments were made about staffing levels which were felt to be inadequate at times. This meant that sometimes, there were fewer opportunities for people to enjoy activities and outings. Staff also expressed frustration that sometimes they were only able to provide basic care and keep people safe, rather than engaging in enjoyable activities. They said that with more staff people’s lives would be further enriched.

Holly Lodge provides accommodation with nursing and personal care for up to 18 people with a learning disability and associated health needs. The service is one of many, run by the White Horse Care Trust, within Wiltshire and Swindon. At the time of our inspection 17 people were living in the home. The home had a vacant bed which was used to provide respite care.

The inspection took place on 1 and 2 September 2015. This was an unannounced inspection. During our last inspection in June 2014 we found the provider did not satisfy the legal requirements in two of the areas that we looked at. They sent us a plan of what actions they were going to take to make the necessary improvements. During this inspection we saw that some improvements had been made to address the areas identified during our last inspection.

A registered manager was employed by the service. 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 living at Holly Lodge were not able to verbally tell us what they thought about the care and support they received. Relatives spoke positively about the high standard of care and support their family member received.

The service was responsive to people’s needs and wishes. Care plans were centred on people’s needs and preferences. However daily monitoring records were not always being completed by staff.

We observed staff interacting with people in a kind and friendly manner. Staff always informed people about what they were doing and what was going to happen next.

The registered manager responded to all safeguarding concerns. There were systems in place to protect people from the risk of abuse and potential harm. Staff were aware of their responsibility to report any concerns they had about people’s safety and welfare.

Staff told us they felt supported. Staff received training and supervision to enable them to meet people’s needs. The registered manager and provider had systems in place to ensure safe recruitment practices were followed.

People’s medicines were managed appropriately so people received them safely.

People were supported to eat and drink enough. Where people were identified at being at risk of malnutrition, referrals had been made to appropriate nutritional specialists. There were arrangements in place for people to access specialist diets where required.

Arrangements were in place for keeping the home clean and hygienic and to ensure people were protected from the risk of infections.

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). Appropriate mental capacity assessments and best interests had been undertaken by relevant professionals. This ensured the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, and Deprivation of Liberty Safeguards (DoLS).

There are systems in place to respond to any emergencies. The registered manager and provider had systems in place to monitor the quality of service people received.