Housing 21 - Holm Court

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 outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 93 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The provider’s ethos of providing excellent quality of care, where all people’s voices were heard was shared with each location and oversight of the service ensured the provider’s values were being followed and embedded. Systems were in place to share learning and good practice across the provider’s locations, including lessons learned. The provider’s website stated they were, “Achieving high levels of resident satisfaction and a positive experience for the people we serve.,” which was reflected in our findings during the assessment. The last published satisfaction surveys completed by people using the service had achieved 100% satisfaction.

Staff were kept updated with any changes and the requirements of their role in monthly staff meetings, one to one supervisions, training, policies and procedures, spot checks and supervision. This was important because it helped ensure staff had the knowledge, guidance, and support needed to carry out their roles effectively, which contributed to safe, consistent, and high‑quality care for people.

Staff, including the management team, told us how they were proud working for the service. A staff member told us, “I love working at Holm Court, the staff are friendly, kind and supportive and the residents are brilliant. The [service] is like a big family which I'm honoured to be a part of.” A staff member told us how their family member had previously used the service, they were so impressed by the care and support provided and the ethos and culture within the service, they had applied to work there.

The registered manager and assistance care managers (ACMs) talked about the care staff and each other in a positive, caring and respectful way, this included the pride in how the team worked together. In turn staff spoke about the positively about the management team, including the support they received. The management team and staff spoke about people using the service in a compassionate way and demonstrated a commitment to provide the best possible care. The registered manager told us people’s choices and decisions were central to the service, “I can come and go, this is their home.”

The registered manager told us they, and other members of the management team, had worked all shifts to ensure they knew what the care staff team were doing and could keep it under review. They said this helped them to understand what the care team were being asked to do and checking it was working well and if any improvements needed. Staff were supported to follow a pathway of employment with opportunities to develop in their role.

The provider had exceptionally 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 always did so with integrity, openness and honesty.

Since our last inspection there had been a change in the registered manager of the service. The registered manager told us how they had made changes to develop the service which was continuously improving. A relative told us, “As new management came in there were significant improvements made and excellent communications.” Another relative said, “[Registered manager] joined Holm Court part way through [family member’s] stay and it became very obvious that improvements were being made and I feel that the service with [registered manager] is very well led.”

The registered manager had achieved qualifications relevant to their role, including a diploma level 5 leadership and management in health and social care and National Vocational Qualifications in health and social care.

The registered manager was supported by two assistant care managers (ACM). We found the management team extremely knowledgeable about people’s needs and the requirements of their role. They talked about the staff and people using the service in a caring and compassionate way. The registered manager had taken action to ensure ACM support was sufficient, this included ensuring cover was in place for an ACM who was due to go on leave.

During our visit, we observed the management team being supportive when a staff member was ill, this included arranging for them to be taken to a health care service.

The ACMs undertook staff supervisions, and the registered manager did the ASM supervisions, the registered manager also told us they received a supervision from a member of the senior management team.

Without exception, we received extremely positive feedback about the registered manager and ACMs. A relative told us during their family member’s assessment process, “[Registered manager] won [family member] over and really understood [their] needs… I would not hesitate to recommend Holm Court to others, a well led place that is welcoming to all.” Another relative said, “[Registered manager] was always very approachable, caring and helpful. [Registered manager] frequently went the extra mile to make life better for [family member] and all other [tenants].”

A staff member told us, “Whenever I have raised any concerns they have been dealt with quickly and efficiently.” Another staff member said, “I feel the service is well-led and support is always available.” Another staff member told us, “I personally feel [registered manager] is a very good manager [registered manager] is easy to talk to and tries [their] best for residents and staff.”Another staff member told us. “[Registered manager] is very supportive.”

The provider was exceptional at fostering a positive culture where people knew they could speak up and their voice would be heard.

There were several ways staff could speak up, including following the provider’s management structure. This included national staff forums, the provider’s head of extra care for the south region told us the provider was committed to valuing staff voices and using them to drive improvement.

Staff told us they had access to and understood the provider’s whistleblowing procedures and would report any concerns of bad practice if seen. A staff member said, “I feel that concerns can be raised with the management team and this is welcomed and acted upon.”

Staff had completed surveys which reflected how they felt about working in the service. The responses were analysed and measures put in place to improve experiences. Where comments were received from people using the service and relatives, through surveys, meetings or the suggestion box, actions taken because of their comments were identified in ‘you said, we listened’ documents which were shared with people to demonstrate their feedback was valued.

The management team undertook the provider’s closed culture self-assessment, which helped them to identify any early warning signs of becoming a closed culture and address them. The registered manager told us how this tool was used by the team to prevent any aspects falling into a closed culture. Staff, people using the service and their representatives were empowered to share their views about the service and these were valued and used to drive improvement.

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 registered manager told us there was a diverse workforce who worked well together as a team, based of respect for each other and backgrounds. This was confirmed by staff. The registered manager told us how they had worked to ensure all staff were working in an inclusive and respectful culture.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider’s robust and well-established systems and processes were not just an operational strength but they directly improved the quality of care and outcomes for people. The provider had a range of audits and monitoring systems in place, which assisted the provider and registered manager to identify shortfalls and address them. This ensured people were provided with a high-quality service. Where shortfalls were identified, action plans were put in place with timescales for completion, and progress and outcomes were regularly reviewed.

All documentation and audits could be accessed by the provider’s senior management and regional teams; this ensured the governance systems could be monitored and any emerging issues quickly addressed. We saw the registered manager was consistently achieving the provider’s targets, for example in completion of monitoring systems and staff training. The registered manager showed us the electronic system used for monitoring the service including how care plans were reviewed, the system alerted the management team if any audits were later than the planned time.

The registered manager told us they had a contingency plan for emergencies in place, we saw this information was accessible to the staff team which provided guidance for staff and actions to take in an emergency, such as evacuation or power loss. The service’s records were maintained electronically, however, there was a system to revert to paper immediately if needed for example, if the electronic system was not working or a power failure.

Spot checks were undertaken, which included observing staff when they were supporting people to ensure they were meeting the required standards. As part of the spot check process, people were asked for their views about the care worker and their experiences of being supported by them, this was called, ‘care to share’. This feedback was used as part of the staff member’s one to one supervision. This was important because it ensured people’s views directly informed staff development, helped address any concerns promptly, and supported continuous improvement in the quality of care provided.

Certificates were in the office which demonstrated the service’s ongoing compliance with the provider’s training requirements and gave assurance that staff were appropriately trained to carry out their roles safely and effectively.

The electronic care planning system set out tasks for the care staff attending to the person’s care visits. Where tasks were not completed, an alert was on the system which could be seen by the management team to ensure appropriate action was taken.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

The registered manager told us they worked well with other professionals, including commissioners and took any feedback received seriously and used it to improve the service. A commissioner told us, “[Registered manager] is good at contacting me if there is an incident or to ask a question.” The registered manager told us how they worked well with the district nursing team, who had provided training where people had specific needs, such as equipment used.

A staff member told us how they had made a bid to the provider and had been awarded a sum of money for a sensory garden. They were working with the people who used the service and a meeting was arranged with a local college to discuss what support from students could be provided to develop the garden. Following our visit the registered manager told us this meeting had been successful, and an agreement made for work in partnership with the college, people using the service and staff to develop the sensory garden. In addition, a staff member told us how they had contacted other community organisations with plans to include areas of wildlife, such as bees and hedgehogs.

The service had close ties with local places of worship, this included regular coffee mornings with church volunteers and people using the service, and people’s participation in making art pieces to be displayed in the church, along with others. Plans for people to visit to see all of the art. A staff member told us how the people using the service had made a scarecrow that been part of a local scarecrow trail.

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 registered manager told us they recognised requirements in the care industry consistently changed and ensured staff received the training they needed which was kept updated to drive continuous improvement. Staff were provided with training and the opportunity to undertake qualifications relevant to their role. Staff were kept updated with any changes to the requirements of their role through meetings and supervisions. The registered manager told us even if staff had achieved training and the care certificate in a previous job role, they were still asked to complete this in their induction to ensure they were trained to the provider’s standards. Regular knowledge checks were undertaken by staff in areas such as equality and diversity, and the management team checked staff’s competency, in areas such as moving and handling. This supported the management team to identify if staff required additional training.

Newsletters were sent people using the service to keep them updated with any changes within the service, and any planned improvements. This helped ensure people were well informed, involved, and reassured about how the service was developing, promoting transparency and trust.