About the service: Holly Lodge Residential Home is a residential care home that accommodates up to 22 older people living with dementia. People had other care needs such as, Parkinson’s disease or were recovering from a stroke. Some people were cared for in bed, some people needed help with moving around and others were able to mobilise independently. At the time of our inspection there were 18 people living at the service.

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 inspection was carried out on 22 December 2016 and was unannounced.

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

We carried out this inspection on the 12 November 2015, it was unannounced.

Holly Lodge is a care home providing accommodation and support for up to 22 older people who are living with dementia. It is over three floors and there is a stair lift available to access the first and third floor. At the time of the inspection 19 people lived at the service. The third floor was not being used.

There was a 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.

Medicines were not being administered in line with the NICE (The National institute for clinical excellence) ‘Managing medicines in care homes’ guidelines.

People were given individual support to take part in their preferred activities. However, there were no planned trips out of the home into the community. There were some activities taking place, however there was no schedule of activities so people could see what was going to take place. We have made a recommendation about this.

There were audit systems in place to make sure the staff provided a quality service and keep people safe. However issues raised by these audits were not always followed up.

People were provided with meals that met their needs and preferences. Menus however did not offered a good variety and choice. People said they liked the home cooked food. Staff made sure that people had plenty of drinks offered through the day. We observed lunch being served and people seemed happy; although staff did not remind people what the meal was that they had chosen. Staff gave appropriate support to people who needed assistance to eat their meal. We have made a recommendation about this.

People demonstrated that they were comfortable at the service by smiling at the staff who were supporting them. Staff were available throughout the day, and responded quickly to people’s requests for care. Staff communicated well with people, and supported them when they needed it.

There were systems in place to obtain people’s views about the service. These included one to one meetings with people and their families and an annual survey.

The providers investigated and responded to people’s complaints. People or their family knew how to raise any concerns and were confident that the manager would deal with them appropriately. People and relatives told us they had no concerns.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Applications were being completed in relation to DoLS, the providers understood when an application should be made. They were aware of the Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty. The service was meeting the requirements of the Deprivation of Liberty Safeguards.

Staff had been trained in how to protect people, and they knew the action to take in the event of any suspicion of abuse towards people. Staff understood the whistle blowing policy. They were confident they could raise any concerns with the manager or outside agencies if this was needed.

People and their relatives were involved in planning their care, and staff supported them in making arrangements to meet their health needs. The providers and staff had contacted other health professionals for support and advice.

Staff were recruited using procedures designed to protect people from unsuitable staff. Staff were trained to meet people’s needs and they discussed their performance during one to one supervision which currently is only twice a year. They also had an annual appraisal. We made a recommendation about this

There were risk assessments in place for the environment, and for each person who received care. Assessments identified people’s specific needs, and showed how risks could be minimised. There were systems in place to review accidents and incidents and make any relevant changes to reduce further harm.

You can see what we have asked the provider to do with regards to any breaches in regulation at the end of this report.

The inspection was carried out by one inspector of a time period of 3.5 hours. We were following up on a previous inspection on 8 May 2014 that found some of the regulations were not being met. We were able to answer two of our five questions; Is the service caring? Is the service safe?

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.

Two inspectors visited the home, during this visit we were able to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

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.

Following the receipt of concerning information we visited Holly Lodge at 05:00am in the morning. We saw that four people slept in arm chairs in the lounge as staff had not been able to either persuade them to go to bed or the person had got up early.

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.

The inspection was carried out by one Inspector over five hours. We found that the home had a relaxed and friendly atmosphere, and people said that they liked living there.

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.

People told us that they were happy living at the home. They told us that the food was very good; that they liked their rooms and that the staff were friendly and helpful. People said that staff respected their privacy and assisted them in a caring way. One person said “there’s a sort of a good feeling here.

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.

A person who had been recently admitted to the home said that the manager had been to visit them in their own home first. They had found this to be a helpful experience.

A relative said that there had been discussions with them about all of the person's health and care needs, and they were fully involved in every decision which the person could not make without support. They said that they could go to any of the staff to talk about anything, and that the staff always contacted them if there were any incidents or changes in care.

We had individual conversations with six people living in the home, and talked briefly with four others. They said that they were very happy in the home, and could do what they wanted. One said "I don't like doing activities, I like sitting and chatting". Another said that "there are lots of things to do if I want to", and another said "I like gardening". One person said they were very concerned about a personal situation, and "the staff know all about it and are very supportive".

People living in the home said that the staff were very helpful, and would spend time chatting with them or playing games. A visitor said that they saw staff spending lots of one to one time with people.

People said that they could choose what they wanted to eat each day, and that the meals were well cooked. One person said "I often can't remember what I have asked for, but it is always good". Another person said "I really liked the lunch today".

A relative of a person living in the home said that their bedroom was "always spotlessly clean, and tidy". One person commented that they liked their bedroom. Another person said they liked being able to sit in the lounge with other people. Two others said that they enjoyed going out into the garden.