Holme Lea

Updated 4 November 2025

This assessment was carried out between 12 and 26 November 2025 and was unannounced. The service is registered to provide care and support for up to 48 people. At the time of our visit there were 46 people using the service.

We identified two breaches of legal requirements relating to the management of medicines and the systems for oversight and governance at the service.

We found significant concerns in how the service managed time-sensitive medicines and medicines where doses require regular review. We also found issues with the management of topical creams and record-keeping for the application of creams and thickening powders used in drinks. Improvements had been made in the use of variable-dose medicines and guidance for medicines needed occasionally, such as pain relief. Systems in place to ensure lessons were learnt were not always effectively used. Improvements were needed to care plans, risk assessments and record keeping within the new care planning system. Staff were safely recruited but people did raise some concerns about staffing levels within the home

People were supported to access health care services when needed and there was ongoing work to ensure people’s health needs were met, including work relating to falls and nutrition. Staff asked people’s consent before providing support.

Overall, staff were kind and caring and knew people well. Independence and choice were generally promoted.

People were mostly happy with the support they received and felt staff ensured they got the care they needed. However, care plans and records did not always reflect personalised care, and there was limited evidence that people and their families had been involved in developing care plans. There was also little evidence of support for future planning. One person receiving end-of-life care did not have a care plan reflecting their needs. However, this was quickly addressed by the registered manager.

The registered manager was committed to improving the home. Due to periods of absence, the provider arranged management cover, which led to some inconsistency and gaps in oversight. Processes were in place for audits and checks, and while these identified some issues, improvements in care plans and records had not yet been fully implemented. The oversight systems also failed to identify the most significant risks we found in relation to medicines.

Updated 4 November 2025

Most people spoke positively about their experience of living at the service and spoke highly of the staff. One relative commented, “The staff are professional and go over and above in interactions.” However, feedback about staffing levels raised concerns that there were not enough staff available to provide support at the times needed. One relative said, “[Family member] is usually in the lounge. I notice that for long periods there are no carers around. I think there is a lack of staff. Some residents fall down and [family member] helps them up.” Another relative commented, “There could be more staff. A lot of the time the residents are just stuck in their chairs doing nothing. I don’t think the staff have got time to spend time with them. I try and talk to them when I am there.” We observed several occasions when staff were not visible, and we had to assist a person to seek support. Staff also raised concerns about staffing levels. However, when staff were available, they were very responsive to people’s needs.

We received some concerns from people about the provision of personal care. While we noted that people were regularly washed, records showing support for bathing, showering, and hair washing were limited.

People appeared to enjoy the activities available in the home, which included quizzes and some trips out. However, several people expressed that they would like more to do. There was only one activity worker covering all units, and this role was not covered during days off or holidays.

People appeared to enjoy their food. One relative commented, “[Family member] is a good eater. I saw some afternoon snacks of crackers with pepperoni and cheese being given out in the lounge when I was there. They do get a choice of food.”

People and families gave mixed feedback about communication. The majority of people told us communication worked well, with one relative commenting, “If there are any problems, they are on the phone straight away.” However, this had not been everyone’s experience, and another relative told us, “They might mention something if you are visiting, but if you are not there, they don’t tend to contact you. The only time they do is if [family member] needs to go to hospital.”