Archived: Holly Lodge

Updated 24 December 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors and an assistant inspector.

Service and service type

Holly 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 service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We gave a short period notice of the inspection to check the coronavirus status of the home and because some of the people living at Holly Lodge may require notice of visitors.

What we did before the inspection

We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We looked at notifications the provider sent to us. Notifications are information about important events the provider must inform us of by law.

We used all of this information to plan our inspection.

During the inspection

We spoke with four relatives about their experience of the care provided. We spoke with fifteen members of staff including the clinical operations manager, the registered manager, deputy manager, housekeeping manager, nurses, team leaders and support workers.

We are improving how we hear people’s experience and views on services, when they have limited verbal communication. We have trained some CQC team members to use a symbol-based communication tool. We checked that this was a suitable communication method and that people were happy to use it with us. We did this by reading their care and communication plans and speaking to staff or relatives and the person themselves. In this report, we used this communication tool with six people to tell us their experience.

We reviewed a range of records. This included five people’s care records and multiple medication records. We looked at eight staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with four professionals who regularly visit the service.

Updated 24 December 2021

About the service

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.