Holly House

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.

This is the first assessment for this newly registered service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

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.

We saw evidence of meetings with people who used the service and staff taking place. Really detailed information had been recorded in a number of these records including sharing good practice and areas of improvement. However, we noted that more recent records contained less detailed information than previous dates. They also did not always confirm the manager had been involved in team meetings. However, a representative of a person told us of their, ‘positive impressions’ of the registered manager and new manager and described them as enthusiastic, open to suggestions, and transparent in their communication with external professionals.

Positive feedback had been received in the most recent surveys, from staff and people. The provider told us they had very recently undertaken a survey, and they had received some very positive feedback in this. A range of information and guidance was available to support people, feedback in the form of you said we did was on display that demonstrated the provider listened and acted on feedback.

All of the management team spoke about their commitment in the service and discussed their aspirations for the future. Whilst a new manager had taken over during the assessment they were not new to the service, and it was clear they were passionate and committed to both the people living there and the staff who worked there. All members of the management team open and transparent and committed to service delivery for the people who lived there.

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.

Some of the staff team were positive about the registered manager but others talked about the changes in management and how it had impacted on how they felt supported and engaged in the service. Some people fedback that the change in management had been difficult, but they were happy. Comments included, “[Registered manager] doesn’t really interact with staff and people as much. He is very new to the home and company. If I was worried about something I would go to [the new manager], but I am comfortable reporting concerns to [registered manager]”, “The last manager opened doors for staff so we could express our feelings, that was what everyone would want a manager to be. What anyone would wish for. The new (registered) manager I don’t know that well” and, “I find all managers approachable.” We agreed with the provider that it can be difficult for new management when they take over in a service when an established long term manager moves into a different post.

There was a regular senior team presence, and it was clear from our observations and interactions that people and staff knew them well. The management team demonstrated their understanding and operation of the service. The registered manager discussed the support they had received from the senior team. The registered manager told us, “I am coming in with different eyes, I am very good in mentoring people and change ways of working and in staff understanding what they are doing and why.”

Staff told us regular meetings were taking place in a variety of formats that enable sharing good practice and learning from events. Records we reviewed confirmed this. Staff said there was a, “Good culture at this service. Everyone’s best interests are for the residents.”

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

The management told us there was an open-door policy and we observed staff engaging with the management team on both days of the assessment. Staff feedback was mixed about the management and who they felt more confident in approaching and would be listened to. However, 1 staff told us, “With regard to freedom to speak up, I am happy to do so. We have staff meetings once a month and residents’ meetings once a month. It is all confidential. When concerns are raised they are acted on straight away.” Regular supervisions were being held with the staff team, a system to record and monitor these were ongoing.

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.

Staff had undertaken a range of training that supported them to deliver person centred care to people. A wide range of meetings were taking place across the service. Meeting minutes included information about areas discussed and feedback.

We observed positive, kind and caring interactions between all of the staff team and the management. A range of information, policy and guidance was available for all of the staff to access to support them equally in their roles.

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.

A detailed range of records confirmed audits and oversight of the service was being undertaken and were thorough. These included actions, the date to be completed and when these have been done. Up to date guidance and policy was in place and available to support people, using best practice guidance. A statement of purpose and business contingency plans had been developed to support the service in the event of an emergency. Notifications were being submitted to the Care Quality Commission as required. Information was being stored securely, and confidential information was locked away.

The inspection was supported by the registered manager, the deputy, the previous registered manager as well as the regional manager. All of the management were very supportive and engaging with the assessment and were open and transparent. Requests for information and evidence to support the assessment was provided very promptly and the provider took immediate action as a response to recommendations made during the assessment process. The registered manager was in the process of leaving the service and a new manager had been recruited into post and would be applying to be the registered manager with the Care Quality Commission.

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.

The service worked with a range of professionals. We saw evidence of professionals involved in people’s care, this included health partners. Some partners were positive about the relationships with the service but others fedback that this could be better with regard to acting on advice from professionals. One person’s representative discussed their positive impressions of the new registered manager, and the management at Holly House, describing them as, “Enthusiastic, open to suggestions, and transparent in their communication.”

People were being supported to go out into the local community; undertaking planned activities of their choice. However, a representative fedback that activities could be more frequent for people. People told us they could go out into the community, and we observed people accessing community activities during our visits and discussing activities with the staff about what people liked to do and how these could be supported.

The provider discussed the measures they took to encourage and engage the people they supported with meaningful activities both in the service as well as in the community. They also talked about charity and engagement events across the organisation raising money for good causes in the local area.

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 senior management team discussed the innovative way they had improved the life of 1 person in adaptions to their personal accommodation, working with them to access their personal space effectively.

Staff told us and records confirmed a range of training, supervision and checks were ongoing. This would ensure staff were skilled and supported to provide a fulfilled life and care to the people they supported.

Good evidence of lessons learned was seen that supported embedding changes and learning from events to improve people’s care. There was evidence that the management shared updates with staff in regular meetings. A range of policies and guidance was in place. These were up to date and included links to national guidance.