Holm Lodge

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.

Holm Lodge is a residential care home providing accommodation and personal care for up to 26 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 24 people using the service.

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

Infection prevention and control risks were not always managed safely. Areas of the home which included communal areas and people's bedrooms were not clean on the day of our inspection. The registered manager told us there had not been a cleaner at the service the day before our inspection. However, some of the cleaning required appeared to have been a longer standing issue. There was a lack of oversight of maintenance and infection control issues around the building. Processes were needed to identify and record areas of the home that required cleaning or decoration in order for issues to be addressed in a timely way.

Staffing levels had improved and staff were safely recruited. People told us that staff were available to support them whenever they needed them. There were systems in place to keep people safe from the risk of harm and abuse. Risks to people had been assessed and managed by staff. Medicines were stored and managed safely.

Staff treated people with kindness and respect. People were happy to be at the home and enjoyed the time they spent with staff. Staff told us they felt supported by the management team. The registered manager was open and honest about issues that we found during this inspection and took on board our suggestions for improvement.

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 8 September 2021.) A breach was identified in relation to staffing levels. At this inspection we found improvements had been made and the provider was no longer in breach of regulations. However, concerns were raised around infection control that needed improvement.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

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

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 and will take further action if needed.

We have identified a breach in relation to the premises. 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 from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice. The registered manager had a robust visiting policy that ensured everyone entering the home could provide details of a recent negative covid-19 test.

Holm Lodge is a residential care home providing personal care for up to 26 people. Some people living at the home were living with dementia. Others had support needs associated with older age for example, limited mobility and others had health problems such as diabetes. Accommodation was split over two floors with a lift connecting each floor. At the time of the inspection the home had 26 people living there.

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

Since the last inspection there had been an increase in the number of staff working during the day but the number of night staff remained insufficient to meet people’s needs. Most people needed support with personal care leading to bedtime, having just two members of staff meant that some people were kept waiting for up to two hours. Sometimes people required PRN medicines during the night but staff trained in giving medicines were not always working at night The contingency was to wake a live-in member of staff but there was no on call system in place and on occasion other staff had to be called in from home to help with medicines . There were several people living at the home at high risk of falls. Falls were happening during night-time which put a further strain on staffing. Care plans were not easy for staff to navigate in order to have the guidance they needed to provide consistent support and care. They were not cross referenced with other key documents, for example records of falls. Staff reading care plans would not therefore always have the most up to date information about incidents. Risk assessments were not regularly reviewed.

The management and auditing of falls was not effective. Although falls were recorded and some referrals had been made to the local authority falls team nothing had been done to understand the root causes of why people were falling. The auditing process did not identify the type and frequency of falls to identify if falls could be reduced over time with some people experiencing up to 12 falls in a three-month period.

A safeguarding policy was in place and staff told us the steps they would take if they had any concerns. Medicines were stored and administered safely. Infection prevention and control procedures were followed although we signposted the registered manager to best practice relating to staff changing before and following their shift and the use of agency staff.

The registered manager had made improvements to the décor of the home and had increased the amount and variety of opportunities to take part in activities for people. Everyone spoke well of the registered manager who provided visible leadership. Staff, people and relatives were all given opportunities to feedback about the home and everyone told us that the registered manager was responsive to issues raised. The registered manager kept themselves and staff up to date with important messages and had fostered positive working relationships with other professionals.

Thorough pre-assessments were carried out with people before they moved into the home to ensure that staff had the appropriate skills to support people. Several people living at the home lived with dementia and staff had been trained in this area and were able to tell us the important aspects of supporting people. Staff induction was effective and opportunities to shadow more experienced staff and time spent getting to know people was in place. People nutrition and hydration needs were met. Staff were supported with their health and social care needs. 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.

During the day , care was delivered in a person-centred way. Staff demonstrated a good knowledge and understanding about people and their needs. Peoples likes and dislikes were considered and efforts were made to make everyone’s day a ‘a good day.’ Independence was promoted and some people were able to go into the community for walks and visits with minimal support. People’s communication needs were met. A complaints policy was in place and accessible to all, complaints being dealt with promptly by the provider. Care for people towards the end of their lives had been reviewed and documented.

Rating at last inspection and update

The last rating for this service was requires improvement (report published 18 October 2019) and there were two breaches of regulation related to staffing and fit and proper persons employed. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection improvements had been made and the provider was no longer in breach of regulations. However, the service remains rated requires improvement. The service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This inspection was prompted by our data insight that assesses potential risks at services, concerns in relation to aspects of care provision and previous ratings. As a result, we undertook a focused inspection to review the key questions of safe, effective, responsive and well-led only. This enabled us to review the previous ratings.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. This is 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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Holm Lodge is a residential care home that provides accommodation and support for up to 26 older people. On the day of our inspection there were 24 people living at the home. Some people had illnesses or disabilities associated with old age such as limited mobility, physical frailty or lived with health problems such as diabetes. Some people lived with dementia and sensory impairment. Accommodation was arranged over two floors with stairs and a stair lift connecting each level.

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

People told us, “I’m fine here, wasn’t safe for me to live at home, but I am safe here,” and “I feel safe and looked after.”

Quality assurance systems were in place and were continuing to be developed and improved. There were areas that still needed to be developed and embedded into everyday practice. Environmental audits and risk assessments needed to reflect that issues identified had been noted and initial action taken to keep people safe, and the full action was delayed due to the pandemic. For example, the replacement of carpets that were rucked. Another area to be developed was the care documentation, to ensure a more person-centred approach to individual risk. At present the approach was generic and not person specific. Staff knew people very well and described how they safely supported people in their daily lives. This however needs to be reflected within the documentation to ensure new and agency staff could provide consistent safe care.

People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible. Staff understood the risks associated with the people they supported. Risk assessments provided generic guidance for staff about individual and environmental risks to their health and well-being. People received their medicines safely, when they needed them. However, improvements were needed in ensuring as required medicines (PRN) were supported by protocols and pain charts.

There were enough suitably trained staff to meet people's needs at the time of the visit. Staffing levels were regularly reviewed following falls or changes in a person's health condition.

We requested COVID-19 infection procedures and policies during the inspection. These reflected current guidance and we were told they were updated regularly. All staff were aware of the government guidance and confirmed that they received updates daily. Staff were all wearing protective personal equipment (PPE).

Staff told us that they felt well supported by the management team and received regular supervision and wellbeing meetings. They felt that improvements to the service had been made and were still being implemented.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Requires Improvement. (published 18 October 2019)

Why we inspected:

The inspection was prompted due to concerns received about peoples’ safety and well-being, medicine management and staffing. A decision was made for us to inspect and examine those risks.

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 coronavirus and other infection outbreaks effectively.

CQC have introduced targeted inspections to follow up on a Warning Notice or other specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.

Accommodation was arranged over two floors with stairs and a stair lift connecting each level.

People’s experience of using this service:

The home was not always safe. The recruitment of new staff was not always in line with current regulation, and paperwork around the control of infection was not complete. The design of the home and lack of dementia friendly decoration added risk for people living with dementia.

Despite this, people felt safe at the home and told us so. Family and friends all spoke highly of the care and the attitude of the staff. We saw staff speak to people politely. People had very few complaints about the home. People told us they were encouraged to bring in their own things to personalise their rooms and make their personal space feel like home. One person told us their relative had spent three weeks in the home following a hospital admission and a quick discharge from hospital. They said “the care was marvellous, and I have no hesitation in using it again if needed. The staff were marvellous”.

People enjoyed the food at the home, one person told us “the food is good here with lots of homemade things.” However, particularly at mealtimes there were not always enough staff to support those people that needed help to eat.

People who were less able to plan their own days could be left with nothing to occupy them. One person told us “I don’t go to the lounge as there are only five seats to see the T.V from and I don’t like aerobics or the activities.” However, people who could, felt able to organise their own time and felt that the staff supported that. One person told us “Staff are so good and so nice and can’t do enough for you. I go to the shop each day and tell staff when I am going. I go to the shop and there and back takes about half an hour.”

People were supported to be as independent as possible but given help where it was needed. This allowed people to enjoy their time at Holm Lodge without worries. One person told us, “The reason I wasn’t managing at home was because I forgot to take my medication and so I am pleased not to have the worry”. Another person told us, “the staff are very helpful, and kind and I am not at all worried living here.”

Staff knew people well and were welcoming to visitors and family members. One person told us “My family come every week and are always made welcome.”

Staff all told us they enjoyed working at the home. They told us that they felt part of a good team, and all said that the manager supported them in their roles; more information is in the full report

Rating at last inspection: At the last inspection the service was rated Good. (Published 16 December 2016)

Why we inspected: This was a planned inspection based on the rating of the last inspection.

Enforcement : Action we told provider to take (refer to end of full report)

Follow up: We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. 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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

There was a registered manager 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 2008 and associated Regulations about how the service is run.

Building work was taking place at Holm Lodge at the time of our inspection. The provider had failed to fully mitigate the associated risks to people whilst the work was taking place. We have identified this as an area of practice that needs improvement and made a recommendation about robust risk assessments.

People commented they felt safe living at Holm Lodge. One person told us, “Very happy, definitely very safe here.” A wide range of risk assessments were in place and people were supported to take positive risks. People could freely move around the service and spend their days as they wished. However, risk assessments did not always include the measures required to fully mitigate the risk. We have made a recommendation about the oversight of risk assessments.

Care and support was provided to people living with dementia, however, improvements were required to make the environment dementia friendly. We have made a recommendation about sourcing input from a national source on dementia friendly environments.

Staff had received essential training on the Mental Capacity Act (MCA 2005) however, their understanding and knowledge of the Act was varied. Mental capacity assessments had not consistently been completed. We have made a recommendation about MCA training and the implementation of the Code of Practice into care planning process.

Systems were in place to monitor the quality of the service provided and regular checks were undertaken on all aspects of running the service. The registered manager had a range of tools that supported them to ensure the quality of the service being provided. Despite this system in place, the provider and registered manager had failed to recognise that policies and procedures had not been updated to reflect current legislation and guidance. We have made a recommendation about internal review of policies and procedures.

People were supported to maintain relationships with people that mattered to them. Relatives were made to feel welcome and visiting was not restricted. A relative told us, “Always seem to be plenty of staff, who always greet me with a welcome and a cup of tea after my long journey.”

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

People's privacy and dignity was respected and upheld. One person told us, “I can do what I want, come and go within reason and I am treated with the greatest respect.” Another person told us, “Staff are very committed in what they do, very sincere. Staff respect you for what you are.”

Staff were caring and built friendships with people. One staff member told us, “We all adore the residents here.” People told us they enjoyed the food at Holm Lodge. One person told us, “Food is very good, enough choice and amount.” Risks of malnutrition and dehydration were identified and managed effectively and people were supported to have enough to eat and drink.

People, their relatives and staff told us they felt able to approach any member of the management team. They said there was clear communication between the staff team and the management of the service. A visiting relative told us, “The manager is easy to talk to: I have built up a rapport with her. I was involved with the planning and I trust them implicitly with my loved one’s care. The culture is homely.”

During this inspection we spoke with two people who used the service. We also spoke with the providers, the new manager, two care workers and the office administrator. We looked at staff files, recruitment documentation and other records and minutes of meetings.

Following a very unsettled period at Holm Lodge during which six managers came and went, we were told that the provider had now appointed a manager, with many years’ experience of the care sector. The manager told us that they had experience and knowledge of the client group and a sound understanding of the requirements of the regulations. In addition to staff recruitment, training and supervision, they told us that they have extensive experience of assessing, meeting and reviewing people’s care and support needs.

A care worker we spoke with told us, “It’s early days but people seem very happy with how things are now and morale is pretty good. We all just need some stability here but the new manager seems really good. She’s very supportive and very approachable and has settled in really well.”

We found that recruitment procedures had improved and all necessary checks had been carried out before new staff started work in the home.

The manager told us that staffing levels were being closely monitored to ensure that they reflected the assessed dependency levels of people who used the service.

We saw that staff training and formal supervision was being provided and staff told us that they were supported in their work.

People we spoke with told us they were happy with the care they received and with the staff team. One person who used the service told us, "I'm very happy here and have no complaints”. Another person told us, “The staff are very kind here, they know what I like and the food is excellent". Relatives told us that they had noticed general improvements since the new manager had been in place. One relative told us, “Socks needed to be pulled up and hopefully they have been”.

We saw that individual care plans were in the process of being reviewed. This ensured that the assessed current and on-going support needs of people using the service could be met consistently and safely.

Recruitment procedures were inconsistent. Shortfalls that were identified included incomplete application forms, missing dates and employment history and inadequate or unsatisfactory references.

Staff training and formal supervision had “slipped” over recent months. The manager told us they were reinstating regular supervision and were also currently researching external training providers.

We found that the premises were clean and well maintained and the atmosphere was relaxed and homely.

We found that comprehensive and well maintained person centred support plans enabled care workers to meet people's assessed needs in a structured and consistent manner. In accordance with their individual care plans, people were supported to make choices about their daily lives. They had input into how the home was run and were able to influence decision making processes.

Care workers had developed awareness and a sound understanding of each individual's care and support needs. This was evident from direct observation of individuals being supported in a professional, sensitive and respectful manner.

Positive comments from people using the service and their relatives indicated a high level of satisfaction with the home and the services provided:

“I’m very happy here. It’s very comfortable and everyone is so friendly”.

“The staff here are so kind and caring – I’ve got no complaints”.

Appropriate arrangements were in place in relation to storing, administering handling and recording medicines.

We found improvements in the recruitment procedures. Appropriate staff training, risk assessments and safeguarding policies and procedures ensured that people using the service were safe.

As part of this inspection we spoke with the provider the newly recruited manager, the deputy manager, three care workers workers, the home's administrator, five people who lived there and one visitor. We looked at records relating to the running of the home and the personnel files of the manager and seven care workers.

Recruitment practices adopted by the home were unsafe. Relevant identity and security checks had not been completed for all staff or checked for authenticity. Staff personnel and recruitment files did not contain all the required information.

There were enough qualified, skilled and experienced staff to meet people’s needs. The care workers we spoke with told us that they felt there had been sufficient number of care workers on duty to meet the needs of the people who lived there, people we spoke with confirmed this. One person told us "They answer the call bell quickly". Another person told us "There's always plenty of girls around to help us".