Hollyfields

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 75 (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 registered manager promoted the provider’s values within the team to enable them to be embedded in daily practice. They discussed the values during team meetings, reinforcing a shared understanding and commitment. The registered manager shared their vision to deliver high-quality care and foster an open culture where staff felt confident to speak up about concerns. The provider maintained an up-to-date Equality, Diversity and Inclusion policy, which supported a culture of fairness and respect across the service.

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.
The registered manager had the skills, knowledge and experience to perform their role. They were aware of their responsibilities in relation to the duty of candour. This requires providers to be open and transparent with people who use their services and others acting lawfully on their behalf. Staff told us the registered manager was visible within the service. One staff member told us, “The manager comes on the floor and checks how things are going”.
 

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. The promoted a culture where staff felt confident to raise concerns. The speaking-up policy was included in the employee handbook and discussed during staff meetings, ensuring staff understood the process and knew how to escalate concerns outside the organisation if necessary. The registered manager maintained an open-door policy and was visible within the home, which encouraged staff to approach them directly with any issues.

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 told us they felt supported and recognised for their contributions. The provider celebrated achievements through initiatives such as employee of the month, long service awards and the Barchester Care Awards. The registered manager expressed appreciation for the team, stating, “Staff provide good quality care, and they work really hard.” Staff had opportunities to share feedback through annual surveys, and the provider responded to concerns transparently using a ‘you said, we did’ poster, which demonstrated a commitment to listening and acting on staff input.
 

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 had clear governance systems to monitor the quality and safety of the service. Although some shortfalls identified during our assessment were not detected by the provider’s checks, the registered manager responded promptly and took immediate action to address them. Shortly after our site visit, they sent us a written response detailing the actions taken following our feedback. The provider maintained an action plan to track improvements and progress. The registered manager understood their responsibilities and had systems in place to report appropriately to CQC. An up-to-date business continuity plan was available to support staff in the event of an emergency.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff worked with a variety of health and social care partners to ensure people received coordinated and timely support. Care records showed referrals were made to external organisations when needed. For example, staff made referrals to the speech and language therapy team for people experiencing swallowing difficulties. People confirmed they had access to healthcare professionals, with one person told us, “The GP visits on a Monday, and I can ask to see them.” The home also celebrated special events such as birthdays and cultural occasions, which helped foster a sense of community and inclusion.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They implemented governance systems to check all areas of the service and identify shortfalls. When leaders found issues, they created action plans to address them and drive improvements. They ensured staff were informed of any changes or improvements through established communication systems. The provider responded positively to the feedback we gave and took prompt action to address the areas we discussed. Staff recently received additional moving and handling training after leaders identified an increase in incidents. The refresher training aimed to reduce the risk of further occurrences.