The inspection took place on 4 July 2018 and was unannounced. The last inspection to this service was carried out on 19 December 2016 and was rated good throughout with no breaches of regulation. According to our inspection methodology this service did not require an inspection for thirty months. However due to concerns received about the service from a whistle blower and several concerning notifications we brought the inspection forward. During our inspection on 4 July 2018 we found this was no longer a good service and identified breaches of regulation around person centred care, consent, safe care and treatment, staffing, the premises and equipment and clinical governance. Since the last inspection the registered manager had left and a new manager came into post in November of last year. They told us they had made some significant changes to the service and had in place a detailed action plan they were working towards. We were confident in the manager’s ability to identify and bring about positive change to the service. We were less confident in the overall management and oversight of the service by the registered providers. The service is registered for up to 27 people who primarily have a mental health need. However, people might also have a learning disability, a diagnosis or autism or issues relating to alcohol and substance misuse.
The Hollies and Holly 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 service is divided into two separate units joined by corridors. The main house accommodates most people and has shared communal areas and communal showers. It offers single occupancy bedrooms and generous gardens and grounds. The second part of the building has fewer number of people and separate communal facilities and separate staffing.
During our inspection on 4 July 2018 there was a manager in post but they were not yet registered with the Care Quality Commission although they advised us they had put their application in and had been waiting at least twelve weeks.
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.
At this inspection we found people were receiving care that was not always safe or met their identified needs. The manager had taken actions to try and ensure people got their medicines as intended after a series of medication errors. This had resulted in either people not getting their prescribed medicines or medicines administered incorrectly. There had also been issues with accounting for medicines to make sure they were available as people needed them. The manager had put more robust procedures in place and had supported staff to ensure they were competent and had accessed the right level of training.
The manager confirmed they had significantly increased the staffing levels since coming into post including the introduction of waking night staff. However, we were unable to see what people’s assessed needs were as some people had not been reviewed for some years. Some people had high risk behaviours which could put themselves or others at risk. Staffing levels meant that people were not always supervised for their safety and were not sufficient for people to have personalised care around their needs. The service did not have a dependency tool in place to show how they calculated the numbers of staff they needed.
The environment was not safe for its intended use. We found during our inspection broken window restrictors, ligature risks, uncovered radiators, water that exceeded recommended temperatures, and exposed pipework. We also found the environment was excessively hot with little means to keep people cooler. The service had long, thin corridors which were inappropriate for people with a physical disability. Some people using the service were becoming more frail with reduced mobility. Should they need walking aids or be permanently in a wheelchair, the service would not be able to accommodate them safely. The service was not appropriate for people with sight impairment or cognitive impairment as there was nothing to orientate people. The communal areas were too small for everyone to use at once. It was a hot day so some people were outside but others were stretched out on sofas. There were not enough places for people to sit apart from their own rooms and at lunch time there was not enough space for people to safely move between the table and chairs.
Risks to people’s individual safety had not been adequately considered. We observed people unsupervised during the day.This included people frequently accessing the kitchen to make themselves drinks. Staff were not in the vicinity to support people. The risks from cross infection had not been adequately considered and areas of the service were dirty. There were no separate domestic staff and although staff did clean the service they did not have time to do this continuously throughout the day.
Some people’s needs outweighed what the service could provide and the service did not facilitate people’s independence or autonomy. There was nothing in place around assessing people’s capacity to make decisions about their everyday needs or more complex decisions where required. The manager was in no doubt that some people had fluctuating capacity and there were no systems in place to support effective decision making to ensure it was in people’s best interest. The manager was in the process of getting everyone needs re reviewed and where necessary carrying out capacity assessments. They had reviewed lots of care plans to ensure they accurately reflected people’s needs and provided evidence of how staff were meeting these.
However not all the care plans were up to date and it was difficult to establish what everyone’s needs and risks associated with their care and support were. It was difficult to establish from their records how their health care needs were monitored and met by other professional staff.
There was nothing in place regarding end of life care, and people’s preferences regarding this were not clearly established. Staff had not been given training and this was of a concern given a few recent deaths.
Activities for people were provided but it was difficult to assess if they were sufficient or around people’s assessed needs and in keeping with their life experiences.
The meal time experience was poor and staff did not enhance people’s wellbeing although we saw people did enjoy the food provided. Meal sizes did not consider people’s preferences, neither were they proportionate in terms of those who had been steadily gaining weight. Weights were monitored but we could see little recorded actions regarding weight gain and promoting healthier lifestyles where appropriate.
The manager was experienced and had set about bringing positive change to the service. They had a full staff team and had recently recruited a senior team to help improve the service. They had put in systems to help them measure the effectiveness of the service and identify anything where improvements were required. A new maintenance person was on site and focussing refurbishment and ensuring equipment and premises were well maintained.
Staff recruitment processes were adequate and the manager had improved training opportunities for staff and ensuring staff received adequate support and supervision for their job role.
Staff had sufficient understanding of protecting people from abuse and had received training. We had concerns about the management of incidents as records did not always tell us what actions had been taken and if risk assessments were in place and had been updated.
Overall although we have rated this service as requires improvement we found people were happy with the service and the staff that supported them. We were confident with the new management arrangements and felt given time this service could be turned around to become a good service. We have received assurances that the building is being completely renovated and the service is going to provide a second regulated activity of personal care in people’s own homes. This would increase the scope of the service to provide care and support around people’s assessed needs and become more personalised. We do however have reservations about provider oversight given the level of concern we identified. We also want assurances that the action plan continues to be met and plans for refurbishment and the rebuild go ahead as scheduled.