Holbeach Meadows Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this newly registered service. This key question has been rated outstanding. This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

This service scored 88 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People received a comprehensive assessment of their needs when they moved into the home. These assessments were reviewed regularly, at least monthly, to ensure any changes in health, wellbeing, or preferences were identified and reflected in their care plans.

Care plans were person-centred and responsive to changing needs. Staff worked closely with people and their families to ensure care remained appropriate and supportive. A relative commented in a recent survey, “We feel that [Name’s] care is exceptional and whilst it has become more and more difficult for us to navigate their deterioration due to dementia, we feel that the care home gives 110% care and attention, ensuring that [Name’s] life is as happy and comfortable as possible.” This feedback reflected the commitment of staff to delivering high-quality, compassionate care that promoted dignity and wellbeing, even as people's needs became more complex.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff demonstrated a clear understanding of evidence-based approaches and applied them effectively to meet the individual needs of people. For individuals who experienced episodes of distress, clear guidelines were in place to help staff identify potential triggers, support the person through their distress, and minimise the use of medication. For example, one person’s care plan specified that only one staff member should support them at a time, as additional staff presence could increase their distress. Furthermore, medication was only to be considered after staff had first offered reassurance, food, drink, and supported the person to use the toilet.

This person-centred approach meant the individual received care that respected their preferences and reduced unnecessary interventions. Staff were observed following these guidelines consistently, which contributed to a calmer environment and improved the person’s overall wellbeing.

People who required modified texture diets were supported in accordance with the international dysphagia diet standardisation initiative (IDDSI)framework. The catering team had received targeted training and practical support to ensure meals were prepared and presented in line with these standards. Kitchen staff were provided with information-based training sessions, supported by visual materials and posters to reinforce IDDSI principles. This was followed by hands-on guidance in the kitchen to embed learning and ensure consistency.

Staff were taught techniques to present modified texture foods in a way that maintained their recognisable appearance, using tools such as piping bags. This approach promoted dignity and familiarity for people, enhancing their mealtime experience. Care staff reported residents were more likely to eat meals when they could identify the food presented. This led to improved nutritional intake and greater engagement at mealtimes. Catering staff expressed increased confidence and pride in their ability to meet people’s’ dietary needs.

The service also used the national early warning score (NEWS) tool to assess and monitor people following incidents such as falls, ensuring timely and appropriate clinical responses. Environmental adaptations supported evidence-based care, including the use of blue plates to aid visual recognition and the removal of beakers in favour of more dignified drinking vessels.

Overall, the service demonstrated a strong commitment to delivering safe, effective, and person-centred care that reflected current best practice. Staff were knowledgeable, engaged, and focused on continuous improvement.

The provider always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

The service consistently demonstrated outstanding collaboration across staff teams and external services to ensure people received safe, coordinated, and person-centred care. Staff worked together seamlessly, with clear communication and shared values that placed people’s wellbeing at the heart of everything they did.

People and their relatives spoke highly of the entire staff team, recognising that everyone, from management to carers, kitchen staff, domestic team, and reception, played a vital role in their care and experience. One relative said,“I would like to say that management, carers, kitchen staff, the domestic team, and reception all played an important role in keeping my relative safe and happy and also the family unit. The care was the highest I have come across in a long time and nothing was too much trouble.”

Staff described the team as cohesive and well-functioning, saying,“We have good staff, we have a good team, so it runs well.”This strong team dynamic contributed to a calm, well-organised environment where people felt safe and supported.

Records showed that when people moved between services, comprehensive assessments were shared to ensure continuity of care and avoid the need for individuals to repeat their personal histories. For example, the registered manager collaborated with a dementia specialist team to support a person experiencing frequent episodes of distress that required medication. By working together to understand the person’s needs, identify effective approaches during periods of distress, and review medication use, the team significantly reduced the frequency of these episodes. As a result, the person appeared more settled, was observed walking calmly around the home, and engaged positively with others during mealtimes.

Regular clinical review meetings were held with an NHS nurse practitioner to discuss people with health concerns and agree on appropriate actions. These meetings supported safe, informed decision-making, such as reviewing whether certain medications were still needed or could be safely discontinued. This proactive, multi-disciplinary approach ensured care remained responsive and tailored to each person’s changing needs.

This culture of collaboration, mutual respect, and shared responsibility ensured staff teams and services worked exceptionally well together. People benefited from a joined-up approach that delivered consistent, high-quality care and supported positive outcomes.

The provider always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service consistently delivered care and treatment that was grounded in evidence-based practice and tailored to the individual needs of people living in the home. Staff demonstrated exceptional commitment to promoting wellbeing through innovative, person-centred approaches.

The service demonstrated clinical vigilance. For example, staff identified a pattern of low pulse readings before administering a medication to one person. After three consecutive days, they referred the matter to the GP, preventing potential harm and demonstrating a proactive approach to medication safety.

People living with dementia were supported through the use ofshow plates, where two visual meal options were presented, allowing individuals to point to what they preferred. This method respected autonomy and supported decision-making in a way that was accessible and dignified. For example, one person who had experienced weight loss prior to admission began to regain weight through a personalised nutrition plan, including the use of visual “show plates.”

Snack stations were available throughout the home, and staff ensured people had access to food and drink at all times, including during the night. This approach helped prevent malnutrition and supported people to maintain a healthy weight. The service promoted healthier living through a well-balanced diet. Healthier options were always offered, while ensuring people retained the freedom to choose what they wanted. Where people were identified as underweight, referrals were made to their GP and nutritional supplements were prescribed as appropriate.

During a period of hot weather, staff implemented a proactive hydration strategy, offering ice lollies, shaded outdoor spaces, and regular prompts to drink. This helped prevent dehydration and ensured people remained comfortable and well.

Feedback from relatives highlighted the high quality of care provided. One survey response stated, “An excellent home … the staff are very caring and do their utmost to involve residents in activities and try to enrich their lives with all sorts of things from the hairdresser visits to cinema sessions, entertainment and visits by pets and also children from the local daycare. All these things are above and beyond the normal scope we often see in care homes these days.”

Physical activity was a key part of the home's approach to healthier living. A walking club operated throughout the year, encouraging people to walk or enjoy fresh air in wheelchairs around the grounds. Weekly exercise offered engaging and inclusive opportunities for movement. For those with limited mobility, armchair exercise sessions ensured everyone could participate. People also enjoyed a variety of active games, including carpet bowls, mini golf, pétanque, and target games, which promoted movement, coordination, and social interaction.

The games room was stimulating space, featuring a pool table, air hockey, table tennis, a dart board, giant Connect 4, and bar billiards. These activities provided fun and engaging ways for people to stay active and socially connected. In addition, the Gardening Club offered gentle physical activity and a connection with nature, while meditation and wellbeing sessions supported emotional and mental health.

Staff consistently went above and beyond to ensure care was not only safe and effective, but also respectful, engaging, and tailored to each person’s preferences. This was evident in the way staff responded to individual needs with compassion. For example, when one person was found to be hungry at night, staff adapted their approach by stocking fridges with extra sandwiches and providing soup that could be heated up, ensuring nutritional needs were met outside of standard mealtimes. This approach proved effective, as the person became noticeably more settled during the night. By having access to food when they needed it, the person was able to sleep more comfortably and consistently. Improved sleep contributed to the person having less distress and enhanced their wellbeing.

The home’s culture of continuous improvement and collaboration across teams was evident through daily clinical oversight, weekly and monthly governance reviews involving regional directors and quality support managers. Staff from all departments, including maintenance, were involved in lifestyle activities, and daily meetings began with care discussions to ensure everyone was aware of people’s needs.

The provider monitored all people’s care and treatment to continuously improve it. They ensured outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The provider consistently demonstrated an outstanding commitment to monitoring and improving outcomes for people. Systems were embedded across the service to ensure care and support were continuously evaluated, refined, and enhanced in response to people’s changing needs, preferences, and feedback. For example, in response to concerns about call bell response times, the service introduced daily monitoring of call bell data and created a ‘You said, we did’ noticeboard to keep people informed of actions taken. This proactive approach enabled the registered manager to identify patterns in when people were most likely to need support, such as during peak times or specific activities. As a result, staff breaks were rescheduled to avoid coinciding with these busy periods, ensuring more consistent availability of support. These changes led to a noticeable reduction in waiting times, enhancing people’s experience and promoting a sense of safety and responsiveness.

Staff used a range of tools and approaches to monitor outcomes, including regular reviews of care plans, nutritional status meetings, and clinical assessments. For example, monthly meetings involving the nutrition and catering team identified people who had experienced weight loss and ensured additional support was provided. This proactive approach helped maintain people’s health and wellbeing.

The service also used evidence-based tools such as the NEWS to monitor people following incidents like falls, ensuring timely and appropriate clinical responses. Staff worked closely with healthcare professionals to review treatment plans and make adjustments where necessary, including the reduction or discontinuation of medication when appropriate. This meant that people received timely and appropriate medical attention after incidents like falls, and their treatment plans were regularly reviewed to make sure they remained safe and effective.

People and their families were actively involved in shaping care and identifying areas for improvement. Feedback was regularly gathered through surveys, meetings, and informal conversations, and the provider responded swiftly to suggestions. For example, when a person was unable to complete jigsaws due to the layout of the lounge, staff adapted the environment to support their engagement without isolating them.

The provider also demonstrated a strong learning culture, using insights from incidents, feedback, and audits to drive improvement. Staff were supported to reflect on practice and implement changes, and additional training was provided where needed. For example, feedback from people living at the home led to changes in the summer menu and targeted nutritional support, including fortified diets and GP referrals for those experiencing weight loss. Staff also reflected on falls and behavioural incidents, implemented medication reviews, and escalated concerns to clinical teams. These actions ensured care remained safe, effective, and responsive to people’s changing needs. This ensured care remained safe, effective, and responsive.

People consistently experienced positive outcomes, including improved confidence, reduced distress, and enhanced quality of life. One person told us,“I don’t give my safety a thought. I had fallen at home and lost my confidence. Since being here, I haven’t fallen and have got my confidence back.”This reflected the impact of the service’s proactive and person-centred approach to monitoring and improving care.

This culture of continuous improvement, collaboration, and responsiveness ensured outcomes were not only met but exceeded. The provider’s commitment to learning and innovation resulted in care that was dynamic, inclusive, and truly outstanding because people consistently received care that adapted to their changing needs, reflected their personal preferences, and led to improved health, wellbeing, and confidence. For example, during a team meeting, staff identified a rise in urinary tract infections and linked this to poor fluid documentation, prompting renewed focus on hydration and accurate recording. In another instance, feedback from people living at the home during a residents’ meeting led to changes in catering, including improved salad presentation, adjustments to pudding options, and the introduction of insulated jugs for sauces to enhance mealtime experience. These examples show how staff reflect on practice, respond to concerns, and implement changes to ensure care remains safe, effective, and responsive.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

The provider demonstrated a clear commitment to ensuring people were informed about their rights around consent and that these were respected when delivering person-centred care and treatment. Staff understood the principles of consent and worked with people to involve them in decisions about their care.

People were supported to make choices about their care and treatment in line with their capacity and preferences. Where people had the ability to give informed consent, staff explained options clearly and ensured decisions were made collaboratively. For those who lacked capacity, staff followed best interest processes and involved families and relevant professionals to ensure care remained appropriate and respectful.

Staff adapted their communication to meet individual needs and supported people to understand their choices. For example, when planning activities or personal care routines, staff took time to explain what was happening and asked for permission before proceeding. One person told us,“They knock on your door before they come in and they wait to be asked as well, which I appreciate.”This demonstrated staff respected people’s autonomy and dignity in everyday interactions.

The provider had systems in place to ensure consent was regularly reviewed and documented. Staff were confident in recognising when a person’s capacity may have changed and took appropriate steps to reassess and involve others as needed.