Holm Lodge

Updated 17 August 2023

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 Health and Social Care Act 2008.

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

The inspection was carried out by 2 inspectors.

Service and service type

Holm Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Holm lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there were 2 registered manager’s in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spent time looking around the service and talking to people who lived there. We spoke with 8 people who lived at the home and 7 members of staff, including the registered manager, the deputy manager, a member of domestic staff and 4 carers.

We looked at a range of documents including 7 care plans and associated documents relating risk management. We looked at medicine administration records (MARs) and documents relating to staff recruitment, auditing processes, quality assurance and the management of infection prevention and control. After the inspection we spoke with 3 relatives and 3 professionals.

Updated 17 August 2023

About the service

Holm Lodge is a residential care home providing personal and nursing care up to a maximum of 26 people. The service provides support to older people living with a variety of health conditions including, dementia, diabetes, depression and alcohol dependence. At the time of our inspection there were 23 people using the service.

People’s experience of using this service and what we found

People’s care plans contained risk assessments that sometimes contained conflicting information. People were given an opportunity to provide feedback about the service but this was inconsistent and it was unclear if any learning or improvement had taken place as a result of what had been fed back. Some audits were found to be lacking detail, with some a series of tick boxes with no commentary or explanation. As a result of inconsistent auditing processes, some issues within the kitchen had not been identified and some themes relating to accidents and incidents had been overlooked.

People and their relatives spoke well of the registered manager and they and their staff presented a visible and helpful presence at the service.

People told us they felt safe and policies and procedures were in place to protect people from the risk of harm. People were supported by a staff team who had been recruited safely and who knew people well. There were enough staff on duty to ensure everyone’s care and support needs were met. Medicines were stored, administered and recorded correctly. Some PRN, as required, medicine protocols were missing but this was immediately addressed by the registered manager. The service was clean and a cyclical process of re-decoration was in place. Accidents and incidents had been recorded.

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.

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 23 August 2022) and there were 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced focussed inspection of this service on 23 August 2022. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve the cleanliness, tidiness and décor of the service.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Holm Lodge on our website at www.cqc.org.uk.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.