Holly House Residential Home

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 remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider ensured staff understood their visions and values for the service. They facilitated a values and vision workshop with staff to reinforce the providers core values and reflect on best practice.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The provider was committed to the service and understood their legal responsibilities. The provider was visible in the service to provide support to staff and ensure the safety and wellbeing of people. We observed the provider interacting positively with people during our site visit. Relatives spoke positively about the provider and the compassion they showed towards the people in their care. A person told us, “[The provider] is such a lovely lady.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff and people’s relatives told us they felt confident to speak up. A staff member said, “I can always talk to the manager. They are very friendly and open-minded.” A relative told us, “The owners are easy to get hold of. I can ring or email and always get a response back.”

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 had the appropriate policies and procedures in place for workforce equality and diversity. Staff told us they felt they were treated equally and fairly, and the provider took action where staff had faced discrimination. The provider supported staff by implementing reasonable adjustments and flexible working where this was required.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The provider was supported with the day to day running of the home by a deputy manager. The provider and deputy manager were aware of their responsibilities and demonstrated a good knowledge of the Duty of Candour and notified the CQC and local authorities of any events affecting the health and well-being of people. Routine audits and checks were conducted, covering areas such as care records, medications, health and safety, and staff practices. However, these audits had not always been effective in identifying all areas for improvement found during the inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Visiting professionals gave mixed feedback regarding working alongside staff and management at the home. However, we found no evidence that this had impacted people’s care. One professional referred to the care staff as being ‘meticulous’ and ‘proactive’. Relatives feedback confirmed that staff worked well with professionals to ensure people’s health and wellbeing was maintained. The provider had formed relationships with the local community including the local primary school.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The provider demonstrated they were open to learning and improving the service by responding to our immediate findings during our inspection. Regular meetings were held with staff to share learning and ideas. A staff member said, “I feel that Holly House is running very well, because we are always open to learn new things.” Staff used technology to support people to communicate with their loved ones. However, further consideration was required in relation to best practice and research for meeting the needs of people living with dementia, such as using digital clocks and calendars to support people’s orientation and independence. This was fed back to the provider for future improvements at the service.