Archived: Holly Lodge

Updated 27 May 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on the 28 and 29 April 2016 and was unannounced. The inspection was carried out by one inspector.

Before our inspection we contacted four visiting health and social care professionals in relation to the care provided at Holly Lodge. During our inspection we spoke with two people living at the service, the manager, assistant area director and three staff. Following our inspection we spoke with three relatives by telephone.

Some people were not able to verbally communicate their views with us or answer our direct questions. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We looked at the provider’s records. These included four people’s care records, four staff files, a sample of audits, staff attendance rosters, and policies and procedures.

The provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

Updated 27 May 2016

The inspection took place on the 28 and 29 April 2016 and was unannounced.

Holly Lodge is a detached house providing residential accommodation for 11 adults with a learning disability and autistic spectrum disorder. The home has seven rooms located on the first floor and one on the ground floor. Within the grounds there is a separate single storey detached annexe which consists of a two bedroom apartment and a one bedroom apartment providing residential accommodation for a further three adults. At the time of the inspection there were nine people living in the home.

The service did not have a registered manager. The previous registered manager had left the service in August 2015. The service was being overseen by a manager from another home within Choice Pathways Limited group. 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.

Some staff had not completed all of the training relevant to their role. Training records showed shortfalls of training epilepsy management personal behaviour support and autism spectrum disorder (ASD).

People told us they were safe and well cared for at the home. People knew how they could raise a concern about their safety or the quality of the service they received.

Staff knew how to identify abuse and protect people from it.

Medicines were ordered, stored, administered and disposed of correctly.

The provider had robust recruitment systems in place.

The service had carried out risk assessments to ensure that they protected people from harm.

There were enough staff deployed to provide the support people needed. People received care from staff that they knew and who knew how they wanted to be supported.

Staff had developed caring relationships with people who used the service. People were included in decisions about their care.

People were provided with meals and drinks that they enjoyed. People were supported to prepare meals for themselves and others.

Policies and procedures governing how the service needed to be run were kept up to date

The manager was knowledgeable about The Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The Metal Capacity Act Code of Practice was followed when people were not able to make important decisions themselves. The manager understood their responsibility to ensure people’s rights were protected.

There was no restriction on when people could visit the home. People were able to see their friends and families when they wanted.

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.