Holly Tree Lodge Residential Home Derby

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 – 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 good. At this assessment the rating has changed to 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 good governance. This was because systems to support quality, safety and continuous learning were not operating effectively.

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 clear shared vision, strategy and culture for the service but lacked a fully developed culture of continuous improvement.

Whilst the culture of the service promoted person-centred care, sufficient scrutiny was not consistently prioritised. The risks identified during the assessment had not been recognised by the provider and action plans were not in place to address the shortfalls at the service.

We spoke at length with the registered manager and deputy manager. Both were highly experienced in their field and had been working in health and social care for many years. We acknowledge a lot of work had taken place to maintain a positive culture within the home. However, the provider had not developed a clear and consistent approach to driving improvement across the service. There was limited evidence of how the provider’s vision was translated into practice.

Staff we spoke with understood what a closed culture looked like. They told us they would report poor practice and felt confident concerns would be acted on by management.

Following our feedback, the provider began to develop a plan to address the concerns identified, including sharing priority areas for improvement with staff.

The provider’s management of the service did not consistently demonstrate the level of attention to detail and structure staff required. Staff did not always have clear guidance supported by robust systems, clear expectations for the roles, or effective oversight of practice.

The registered manager spent a lot of time working alongside the staff team supporting the provision of people’s care. They were visible within the home and spent time speaking with people and staff, which helped maintain an approachable and friendly atmosphere. However, this reduced the time available to fulfil their duties as the registered manager and to ensure full compliance with all regulations.

The registered manager was supported by a deputy manager and a head senior. However, their roles were not fully utilised. For example, senior staff were not consistently delegated responsibility on each shift to check records for completeness or to identify any issues in documentation, such as missing PRN protocols or pre-populated charts.

Staff were consistently positive in their feedback, comments included “[The registered manager] and [the deputy manager] manage superbly. I absolutely do feel supported. “

The registered manager led in a caring and person-centred manner. They were committed to the people cared for and their staff team. The provider has started to act in response to our feedback, demonstrating a leadership that was responsive and willing to act when concerns were raised. However, further time was needed to these changes to be fully implemented and embedded.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us the management team were available during the day and in the evenings, nights and weekends. There was an on-call system where staff could contact a member of the management team if advice was needed. Staff told us they felt able to openly speak up about anything that concerned them.

We observed staff communicating openly with each other and share information throughout the day, which supported a culture where concerns could be discussed as part of normal practice.

Although policies and procedures were out of date, we saw evidence the whistleblowing processes were understood and used appropriately in line with good practice. These arrangements supported a culture where speaking up was encouraged.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider was aware of their duty as an employer, to understand and respect the protected characteristics of staff and to prevent discrimination.

Leaders made reasonable adjustments where required, including adapting duties and working patterns to help staff remain in work. One staff member shared how adjustments had been made to their working pattern in response to changes in their life.

All staff members we spoke with stated they felt they were treated equitably and supported fairly. Staff said they had opportunities for professional development if they wished.

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

Although the registered manager spent time in the service and knew staff and people well, oversight and governance arrangements were not effective in ensuring safe practice. Audits and checks were not effective and did not consistently identify concerns, such as the unsafe management of medicines, environmental risks, or issues relating to staffing levels, as described elsewhere in this report. These included insufficient staff available at key times and people being left unattended in communal areas. These failures placed people at risk of harm.

The provider failed to operate robust quality assurance systems and processes to support the registered manager in identifying the on-going concerns we found. For example, we found inaccurate and unclear information in people’s care plans. That meant opportunities to identify risk and improve care had been missed.

The provider did not follow their own policies and procedures. For example, we were not always notified of events as required. This meant they were not meeting regulatory requirements.

Although the registered manager acted when concerns were raised, these had not been identified through the provider’s own systems. This demonstrated a reactive rather than proactive approach to governance.

The home worked cooperatively with external professionals and sought advice when people’s needs changed. Records showed staff contacted community health teams, GPs and other professionals when support or guidance was required. Staff described positive working relationships with visiting services, which helped ensure people received input from the right agencies at the right time. One professional we spoke with told us, “The home usually take on board advice given. They will also seek my advice if they have any concerns about any of their residents.” Another professional said, “'They engage really well with me, we've got a really good relationship.”

The registered managed told us they encouraged families and friends to be involved in the home through visiting, taking part in events and bringing in pets. Staff supported people to attend appointments or outings and the home maintained links with local services such as the church.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Systems and processes to ensure learning happened when things go wrong were not embedded in practice. Learning from incidents and feedback was shared informally. Although staff told us they reflected and discussed incidents and issues during handovers or when concerns arose, these were not always documented.

Innovation was limited. However, leaders were open to reviewing systems when concerns were highlighted. The provider told us they were planning to involve external professionals, such as care consultants, to support the registered manager and staff team to address the issues identified during this assessment, drive improvements and promote learning.

We spoke with the registered manager about the benefits of liaising with other care home registered managers. They agreed this would support wider learning, sharing of information, and afford opportunities to collaborate with other managers and care homes. The registered manager assured us they would take steps to become more actively involved.