Holme Lea

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Requires improvement. At this assessment the rating has remained Requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision and strategy based on transparency, equity, equality, human rights, diversity and inclusion, engagement, and understanding the needs and challenges of people and their communities. The registered manager was committed to making improvements in the home and was supported by the provider’s management team. Action plans were in place to address areas for improvement.

Not all leaders understood the context in which the provider delivered care, treatment, and support. Leaders did not always apply the skills, knowledge, and experience needed to lead effectively. Some families were unclear about who was managing the service but felt able to approach the care team with any questions.

There had been periods when the registered manager was away from the service, which led to some inconsistency in management oversight and expectations. The registered manager told us they operated an open-door policy and encouraged staff to come for a chat or take a break if needed. However, staff did not always feel listened to, particularly regarding concerns about staffing levels.

People did not always feel they could speak up or that their voice would be heard. There was a policy for raising concerns and whistleblowing, and limited evidence that staff had used it. However, staff told us they did not always feel listened to when raising concerns about staffing levels and were not always confident that these concerns would be treated confidentially. Where people and families raised complaints, there was evidence these had been investigated and action taken.

The provider valued diversity in its workforce and worked towards an inclusive, fair culture by promoting equality and equity for staff. Staff generally felt they were treated fairly, supported, and encouraged in their roles. Appropriate policies and procedures were in place to protect people and staff from discrimination.

The provider did not always have clear responsibilities, roles, systems of accountability, or effective governance. They did not consistently act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate.

At our last inspection, we recommended that the provider ensure all audits were effective in identifying concerns and capturing actions. At this inspection, we found a range of audits and checks in place, but these were not always effective in identifying shortfalls, such as those found during the inspection, for example, in relation to the management of medicines. Where audits had led to action, it was not always clear what the specific areas of concern were, making oversight more difficult. Further work was needed to ensure robust care planning systems were in place, including detailed and personalised information to guide staff, and that accurate records of care were maintained.

The provider understood their duty to collaborate and work in partnership so that services worked seamlessly for people. They shared information and learning with partners and collaborated to drive improvement.

Staff worked well with other services to support people, and feedback from professionals was generally positive. However, care plans did not always reflect specific advice given by external professionals.

The provider did not always focus on continuous learning, innovation, and improvement across the organisation and local system. They did not consistently encourage creative ways of delivering equality of experience, outcomes, and quality of life for people, nor did they always actively contribute to safe, effective practice and research.

Records, such as safeguarding logs, did not clearly evidence oversight of outcomes or learning. Systems for checks and audits were not always completed robustly to identify issues, including those we found during our inspection. However, learning was demonstrated in responses to complaints. The registered manager had completed work on falls prevention and equipment, which they believe reduced the number of falls experienced by people. Further work was underway to support people at risk of weight loss. These processes needed further embedding, and we will review this at our next inspection.