This inspection took place on 9 and 10 October 2018. The first day was unannounced; the provider knew we were returning on the second day.

Holly Tree Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home provides nursing and personal care for up to 41 older people, some of whom may have mental health needs and/or be living with dementia. Accommodation is provided on two floors with passenger lift access between floors. There are communal areas on each floor, including a lounge and dining room. There were 35 people in the home when we inspected.

At our last inspection on 6 March 2018 we rated the service as ‘Inadequate’ and in ‘Special Measures’. We identified seven regulatory breaches which related to staffing, safe care and treatment, safeguarding, consent, dignity and respect, person-centred care and good governance. Following the inspection the provider sent us an action plan which showed how the breaches would be addressed. This inspection was to check improvements had been made and to review the ratings.

At this inspection we found improvements had been made in all areas, although there remained a breach in Regulation 12 (safe care and treatment). This related to medicine management.

The registered manager who was in post at the last inspection in March 2018 left. A new manager started in post in April 2018 and has registered with the Care Quality Commission. 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 environment had improved considerably following redecoration and refurbishment which was ongoing. This included making the home more dementia friendly with themed corridors providing different areas of interest such as a ‘woodland walkway’ with birdsong and open access to enclosed gardens with raised flower beds and seating areas. The home was clean and well maintained.

There were enough staff to meet people's needs and to enable them to engage with people in a relaxed and unhurried manner. Staff worked well together as a team communicating and supporting each other. Staff recruitment processes were robust.

Staff received the induction, training and support they needed to carry out their roles. Staff had been trained in how to manage behaviours that may challenge others. They knew how to recognise early signs of such behaviour and used distraction techniques effectively. Risks to people were well managed by staff, although this was not always fully reflected in people’s risk assessments.

Accidents and incident recording had improved and a monthly analysis considered trends and themes and looked at any lessons learned. Staff had a good understanding of safeguarding and the reporting systems and we saw incidents were recorded and reported appropriately.

Some aspects of medicines management had improved; however we also identified some shortfalls. Following the inspection the registered manager informed us these had been addressed.

People received personalised care although this was not always fully reflected in their care plans. All care documentation was being transferred onto a new electronic care recording system. Care plans that had been transferred were up to date, person-centred and reflected people’s needs and preferences. The registered manager told us all the care plans were being reviewed and would be inputted onto the electronic system within the next two months.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the p

This inspection took place on 6 and 7 March 2018 and was unannounced.

At our last inspection on 1 August 2016 we rated the service as ‘Requires Improvement’ and identified three breaches which related to staff training, safe care and treatment and recruitment. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions in Safe and Effective to at least good.

Holly Tree Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home provides nursing and personal care for up to 41 older people who may have mental health needs and/or be living with dementia. Accommodation is provided on two floors in single rooms with lift access between floors. There are communal areas on both floors, including a lounge and dining room. There were 38 people in the home when we inspected.

The home had 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.

Staff had received training in safeguarding and understood the reporting systems, however we found safeguarding incidents were not always recognised or reported to the local authority safeguarding team. We found risks to people were not properly assessed or managed well, particularly in relation to nutrition, falls and behaviour which may challenge others.

Relatives told us they felt people were safe in the home. However, some relatives raised concerns about staffing levels. Duty rotas showed staffing levels the registered manager said were in place were not being maintained. However, following the inspection the provider told us staffing levels quoted by the registered manager were incorrect. The provider said they were reviewing the staffing levels. Staff recruitment procedures ensured staff were suitable to work in the care service.

Staff completed induction and were up to date with most of their training. However, they lacked the skills and knowledge in how to manage challenging behaviour which put people who used the service and staff at risk of harm and injury. Staff said they felt supported, although they were not receiving regular supervision.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice.

People’s care records were not personalised and did not reflect people’s needs or preferences. There was not enough detail to guide staff about the care and support people required. People’s nutritional needs were not always met, particularly those people who were low weight or had lost weight. People had access to healthcare services and systems were in place to manage complaints.

Medicines management was not always safe which meant people were at risk of not receiving their medicines when they needed them.

Relatives told us there were few activities which our observations confirmed. This had been raised in feedback from surveys people had completed in 2017 but not addressed. Relatives told us staff were friendly and caring. We saw some caring interactions but also practices which showed a lack of respect for people and compromised their dignity.

The provider’s systems and processes did not enable them to effectively assess, monitor and improve the service. They did not monitor and mitigate risk effectively. The provider had failed to notify CQC of incidents which are legally required to be reported.

We found shortfalls in the care and se

The inspection took place on 1 August 2016 and was unannounced, which meant we did not inform anyone beforehand that we would be inspecting.

Holly Tree Lodge is a care home which is registered to provide accommodation and personal care, for people who may have nursing and dementia care needs. On the day of our inspection there were 36 people living in the home.

There was a manager at the service who was registered with CQC. 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.

We last inspected Holly Tree Lodge on 4 June 2015 and found the service was meeting the requirements of the regulations we reviewed at that time.

One person told us, “It’s lovely here. I like it. The girls [staff] are so nice, I love them all, don’t worry about me.”

Relatives told us they thought the staff were competent to do their jobs and said they treated people, “Kindly” and with “Compassion.”

On the day of the inspection we observed two member’s of staff moving and handling a person inappropriately. This posed a risk to both the person and the staff member’s. The moving and handling technique used was not safe and was not in line with the person’s moving and handling risk assessment.

We looked at staff files and found some gaps in the information required to ensure people being employed were of good character. The staff had been employed prior to the provider taking over the service. Although the provider had taken some action to acquire further information about existing staff, some files did not include all the relevant information and documents required to ensure their suitability to work with vulnerable people.

Relatives spoken with said they thought their family member was safe living in the home. They did not raise any concerns about the quality of care and support provided to their family member. Staff had received safeguarding training and were confident the registered manager would act on any concerns.

There was a programme of training that staff were required to complete. The majority of staff had completed mandatory training in such things as health and safety and food safety. We found eight staff (in total) who had not completed training in moving and handling or fire safety since 2014. This training should be completed annually.

The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards (DoLS). This helped to protect the rights of people who were not able to make important decisions themselves.

We found staffing levels were sufficient to meet people’s needs. Staff received induction, supervision and appraisal relevant to their role and responsibilities.

Throughout our inspection we observed people were very comfortable and relaxed with the staff who supported them. We saw people living in the care home were free to move around the home. We saw staff advising and supporting people in a way that maintained their privacy and dignity.

People were provided with adequate nutrition and hydration. Where necessary staff assisted people with their food to ensure they had a sufficient and balanced diet. The mealtime experience was not a positive experience for everyone as there was insufficient space in one dining room for people to sit at tables.

Staff said that communication in the home was good and they always felt able to make suggestions. There were meetings held for all staff and additional meetings for groups of staff, for example, heads of departments. Minutes of these meetings showed this was an opportunity to share ideas and make suggestions as well as being a forum to give information.

The service had a complaints policy and procedure. People and relatives told us they

We carried out an unannounced comprehensive inspection of this service on 13 and 14 October 2014 at which a breach of legal requirements was found. This was because arrangements relating to the management of medicines were not sufficiently robust. Also, consent for care and treatment was not always sought in accordance with legal frameworks, namely the Mental Capacity Act 2005 (MCA).

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook a focused inspection on the 4 June 2015 to check that they had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Holly Tree Lodge’ on our website at www.cqc.org.uk’

Holly Tree Lodge is a care home registered to provide accommodation for nursing and personal care for up to 34 older people living with a diagnosis of, or conditions relating to, dementia. There were 33 people living at the home at the time of our inspection.

The service’s registered manager from our last inspection was still in post. 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 and associated Regulations about how the service is run.

At our focused inspection on 4 June 2015, we found that the provider had followed their plan which they had told us would be completed by the 23 April 2015 and legal requirements had been met.

We saw that actions had been taken so that medicines were managed safely. We saw medication records had improved to capture relevant information about people’s medicines and arrangements for safe storage were more robust.

We saw improvements had been made to evidence that decisions relating to care provision were made in accordance with the Mental Capacity Act 2005 where people lacked capacity. The provider needed to ensure that the principle of ‘least restrictive’ was always considered where potential restrictive practices were in place.

The inspection of Holly Tree Lodge EMI Care Home took place on 13 and 14 October 2014 and was unannounced. The current provider, Trust Care, purchased Holly Tree Lodge EMI Care Home from the previous provider in September 2013. This is the first inspection carried out by CQC under the new provider/company.

Holly Tree Lodge is a care home registered to provide accommodation for nursing and personal care for up to 34 older people living with a diagnosis of, or conditions relating to, dementia. There were 33 people living at the home at the time of our inspection.

There was a registered manager in post at 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 and associated Regulations about how the service is run.

We saw examples of where medicines were not always being checked for accuracy and not being stored safely. Medication records for one person contained inaccurate information about allergies. This meant people were put at risk as medicines were not always managed safely at the service

Observations of the nurse administering medications were positive. The nurse took time with people, ensured required medication had been taken by the person and was knowledgeable about when people needed time critical medication.

Risk assessments were in place and updated as required to help staff manage identified risks in a safe way. Staff received training in safeguarding and were aware of how to identify abuse and the procedures in place to report this. Staffing levels were sufficient to meet people’s needs and staff had gone through suitable checks to ensure they were assessed as safe to work at the home. No one we spoke with expressed any concerns about their safety within the home or with the staff.

People’s care needs were regularly reviewed and specialist advice was sought when required. However, we saw instances where it could not be evidenced that the advice was consistently followed. For example, two people required position changes to help with pressure area care. However we could not see the evidence that this had always occurred. There was a lack of documentation to support that staff had followed the directions in the care plan which meant people could potentially be at risk of pressure sores.

Staff had received training in the Mental Capacity Act 2005 which is legislation to ensure that where a person lacks capacity, any decisions made on behalf of them must be in their best interests. We saw that this Act had not been followed correctly in relation to locking  people’s bedroom doors when they were not in their rooms. As such, the provider was unable to demonstrate that this decision was in each person’s best interests and was suitable for their individual needs.

Relatives told us that their family member’s personalised needs were met. One person told us their family member’s support with transferring was tailored according to the person’s needs. We saw examples of staff being proactive and picking up on occasions where people required assistance.

People received assistance and prompting at mealtimes where this was required and comments about the food were positive. Relatives were able to attend the home and eat meals with their family members.

We saw that staff were caring in their interactions with people and spent time with people socially and not only when care or support was being provided. Staff knew people well although some people’s social histories were not always reflected in their care records. This meant there was not always a holistic view available of a person outside of their care needs. Staff made use of advocacy services to ensure people’s rights were protected.

The provider had made changes at the home and building work was nearing completion. Relatives told us that there had not been any formal meetings since the provider took over. The provider hoped to implement and improve on this in future. The provider did attend the home on a regular basis to speak with people, staff and relatives and monitor the quality of the service.

Staff told us they felt well supported in their roles and comments about the management of the service were positive from external professionals and relatives. People knew how to make complaints and felt able to speak with the provider and the manager.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report