Holbeach Meadows Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 84 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. For example, on one occasion, a person experienced two episodes of distress in one day. A review of their care found that staff had not considered pain as a possible cause. The registered manager reminded staff to routinely assess for pain as a potential trigger and to offer appropriate pain relief.

The registered manager had dynamic systems in place to monitor the safety of care in detail, ensuring all learning was identified and used to positively impact the care people received. This approach contributed to a reduction in incidents and fostered a culture where staff felt fully supported to raise concerns. Staff told us they were confident any issues they raised would be taken seriously and acted upon.

Accidents and incidents were recorded and carefully investigated. Immediate action was taken to resolve issues, and healthcare professionals were consulted where needed. Detailed information was added to care plans to help staff support people through periods of distress and prevent recurrence. Care plans were reviewed after each incident to identify changes that could reduce future risk or minimise impact.

Monthly audits of incidents were used to identify trends and inform service improvements. For example, staffing levels were increased in the afternoons after data showed this was when most incidents occurred. Where staff performance issues were identified, reflective sessions were held, and additional training was provided to support improvement.

Learning was shared consistently across the team through handovers, team meetings, and supervision. Staff were knowledgeable about incidents and the lessons learnt. For example, when one person became distressed at night, staff identified hunger as the cause and introduced access to hot food overnight, which resolved the issue.

The registered manager also proactively sought feedback from people and their relatives to identify potential risks before they occurred. This insight was used to prevent harm and improve care. Relatives confirmed their feedback was valued and acted upon. One said, “Even when we’ve mentioned something we thought might enhance [Name’s] life a little, the staff take time to listen and have often implemented things before we’ve even thought of them.”

In addition to incident-based learning, the service promoted a culture of continuous improvement. Staff were encouraged to reflect on their practice, share ideas, and contribute to service development. Learning was celebrated through recognition in meetings and supervision, reinforcing its importance in delivering safe, high-quality care.

This embedded learning culture ensured safety was continuously improved, staff felt empowered, and people received care that was responsive, compassionate, and truly outstanding.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place to ensure information about people’s health and care needs were shared when they moved between services. A relative noted in a survey completed for the home, “[Name] initially entered the home for two weeks respite care, but it became rapidly apparent they were unable to return home. The care home management were exceptionally understanding and did everything they could during a very emotional time for us, to ensure that the transition into full time care was managed in a very sympathetic and extremely understanding manner.”

The provider worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. Staff had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider always shared concerns quickly and appropriately.

People told us they felt safe at the home and had no anxiety about living there. One person said, “It is just safe here, I don’t think about it.” Another commented, “That’s a funny question to ask. I don’t even think about my safety, I just live here and get on with it so I suppose I assume I am safe.”

People attributed their sense of safety to the staff and the secure environment. Staff were consistently visible, checked in regularly, and responded promptly to any needs. One person told us, “I feel safe here, I just do. Nothing worries me and the staff are here to look out for me.” Another said, “I do feel safe here. The [staff] are always around, and you are locked in so strangers can’t just walk in.”

People felt confident raising concerns and knew they would be listened to. One person said, “I am not worried by anyone here. I can talk to the staff if I need to.” Records showed when concerns were raised, the registered manager took them seriously, carried out thorough investigations, and took decisive action to protect people. The registered manager worked collaboratively with external safeguarding agencies to ensure people were protected and their rights upheld. This joint working approach enabled timely and effective responses to safeguarding concerns, drawing on the expertise and authority of external professionals to support robust decision-making. It also demonstrated a commitment to transparency and accountability, helping to build trust with individuals, families, and regulatory bodies.

Staff had received safeguarding training and were confident in recognising signs of abuse, neglect, or distress. They were vigilant in monitoring people’s wellbeing and understood how to raise concerns appropriately. For example, when supporting family members who lived in the home, staff ensured no one became overwhelmed by the other’s needs, demonstrating thoughtful safeguarding in complex situations.

Safeguarding was embedded into the culture of the service. Staff discussed safeguarding during handovers, supervisions, and team meetings, and were encouraged to reflect on practice and share concerns openly. Staff told us they felt supported and encouraged to speak up, thanks to the registered manager’s commitment to open communication and mutual respect. One member of staff said, “Managers are approachable and supportive. They help me a lot. They are the best manager I have ever come across.”

For example, the registered manager sensitively engaged in a conversation with a person living at the home who had recently begun a consensual relationship with another individual. The person was living with dementia, and staff took time to ensure they understood the nature of the relationship and their rights. During the discussion, the individual clearly expressed that they were aware of their situation and that they wished to pursue this new relationship. The manager respected the person’s autonomy while ensuring safeguarding principles were upheld, demonstrating a person-centred and rights-based approach.

This proactive, inclusive, and responsive approach to safeguarding ensured people felt safe, respected, and protected from harm.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s care needs were assessed appropriately, and individual risks were clearly identified and documented within their care plans. Risk management strategies were person-centred and regularly reviewed to ensure they remained effective and responsive to changing needs.

Staff had access to full and detailed information on how to support individuals experiencing distress. This included clear guidance on communication approaches and de-escalation techniques tailored to each person. The service worked collaboratively with other healthcare professionals to reduce episodes of distress and promote emotional wellbeing.

Monthly meetings involving the nutrition and catering team were used to monitor individuals’ nutritional status. These meetings identified people who had experienced weight loss and ensured additional support was provided where needed. This proactive approach contributed to maintaining people’s health and safety.

Personal Emergency Evacuation Plans (PEEP) had been completed for individuals who required them. These plans were accessible to staff and ensured appropriate measures were in place to support safe evacuation in the event of an emergency

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

The home was purpose-built to promote safety, well-being, and independence. Hallways were wide enough to allow staff to support people walking safely, with seating placed at regular intervals to offer rest stops. Each floor featured light, open lounges and dining areas, which some people chose to spend time in. A library corridor offered books and games, whilst a cinema room screened films and live events such as the Wimbledon final. A games room was also available, and the registered manager shared that people enjoyed playing air hockey. One person regularly played pool with a visitor, maintaining a cherished routine from earlier in life.

For individuals who experienced distress, a sensory room provided calming music and lights to help them relax. Outside, an enclosed garden was accessible to all, further supporting health and well-being.

Bedrooms were designed with safety and dignity in mind. Each room had an ensuite bathroom with automatic lighting to reduce fall risks and support people living with dementia who may struggle with switches. Beds were 4ft wide, reducing the risk of falls and promoting dignity, as most adults are accustomed to sleeping in larger beds. Bedroom doors featured thumb locks for privacy, but automatically unlocked when the handle was used, supporting people who may forget if they’ve locked the door.

The environment was tailored to support people living with dementia in line with research. Local area photographs were displayed to aid orientation and reminiscence. The registered manager had begun decorating themed areas, such as a kitchen corner and a children’s toy display to stimulate memory. A dedicated reminiscence room featured vintage items like telephones and ornaments. During our visit, one person was seen engaging with a basket of bracelets in this room. This showed that the service understood how helpful it can be for people with dementia to have things they can touch and explore. It demonstrated the service’s proactive efforts to enhance emotional wellbeing and quality of life for people with dementia.

Dementia-friendly signage was being installed to further support independence.

Feedback from relatives reflected the home's outstanding environment. One relative commented in a survey, “When looking around homes just for respite care initially, this home shone and was miles above others we visited. I feel that this home is purpose-built to enhance the lives of the residents.” They added, “It’s not sterile, it’s welcoming, warm and smells wonderful—not only from the meal prep in the kitchen but also in the corridors. It doesn’t smell like a hospital or where elderly residents inhabit, it smells like a hotel.”

Safety systems were robust and well-managed. Maintenance records showed that issues were resolved promptly. Fire safety systems were in place and regularly tested, ensuring the home remained a safe place for people to live.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

People consistently praised the staff who cared for them, describing them as kind, patient, and highly skilled. Everyone we spoke with was positive about the staff, highlighting their attentiveness and compassion. One person told us, “The staff will come and help me if I need it and they will fetch others if they need to. The staff are always around. I have rung my bell in the past and they have always come to me immediately.” Another said, “The staff are amazing and look after us really well. They have a difficult job and are always busy. They have been very kind to me and are always checking if I am alright.”

Staff demonstrated an exceptional awareness of people’s care needs, responding immediately and intuitively, even during busy periods such as mealtimes. We observed staff anticipating needs, including those of people who were unable to verbalise them, ensuring care was proactive and person-centred.

Staff told us they took time to understand each individual, especially when someone new arrived. They engaged in conversations with people and their families to build trust and gather personal insights. This helped them assess risks and tailor support appropriately. One staff member explained, “I try to gauge if they can understand risks, what equipment is needed, and if bedbound, how we can get them out in a safe way.”

The provider also involved people and their families in staff recruitment. When hiring a new chef, candidates were asked to cook as part of their interview, and people and their families were invited to taste and give feedback. People also interviewed other key staff, ensuring new team members aligned with the values and expectations of those they would be supporting.

Safe recruitment practices were firmly embedded in the service. All staff underwent thorough pre-employment checks, including enhanced DBS screening, verification of references, and confirmation of qualifications and right to work. Recruitment decisions were values-based, ensuring new staff aligned with the service’s ethos of compassionate, person-centred care. New staff completed a structured induction programme, which included shadow shifts and mandatory training before working independently. Where additional support was needed, further training and supervision were provided to ensure staff were confident and competent in their roles.

All staff, including housekeepers, completed mandatory training and specialist modules such as dementia care. New staff undertook three shadow shifts before working independently and were supported throughout their transition. If additional training was needed, further shadowing was arranged. Staff were required to complete e-learning and manual handling training before working on the floor, and any concerns about capability were promptly addressed with refresher training.

Supervision and appraisal systems were robust and responsive. Supervisions were carried out by the registered manager and senior staff, with additional sessions arranged if concerns arose. Templates were used to ensure consistency and coverage of all key areas, and the registered manager actively prompted staff to complete required documentation.

This culture of continuous learning, proactive support, and compassionate care ensured staffing was not only safe and effective, but truly outstanding. Staff were empowered, people felt secure and valued, and the service consistently delivered high-quality care that met individual needs with dignity and respect.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The housekeeping staff told us they had a system to ensure all areas of the home were cleaned on a routine basis. The home was spotlessly clean. People told us this was normal. A person said, “They keep the home clean. I think they are good at that.” Another person said, “They do a good job keeping everywhere clean. It is a hard job for them, but they manage pretty well.”

Staff had received training in how to reduce the risk of infection. They were able to tell us how they worked to minimise the risk of infection. For example, how they used protective equipment such as gloves and aprons and worked in line with guidance changing equipment between every person they supported. Staff were clear on the actions to take in the event of an outbreak of illness within the home. This included increased cleaning in the home and supporting people to understand they could not mix as freely as they usually do with others.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People were supported to receive their medicines safely and as prescribed. Staff demonstrated a clear understanding of their responsibilities and followed appropriate procedures to ensure medicines were managed effectively.

People told us they felt confident in the way staff handled their medication. One person said,“I don’t need to think about my medication, the staff deal with all of that. I can’t remember what I take so it is a good job they look after it all.”Another commented,“The staff deal with all my medication. I always seem to get it on time.”This reflected a consistent approach to timely administration and oversight.

Medicines were administered in a person-centred way. One person shared,“I only have paracetamol, oh yes and just one tablet in the morning. They have been fine with it.”Another said,“They deal with my medication and I haven’t had any problems.”

Family members also expressed confidence in the service. One relative told us,“When Dad was in pain they switched to liquid morphine which was the correct decision.”This demonstrates staff responded appropriately to changing needs and worked to ensure people remained comfortable.

Where medicines were reduced or stopped, staff monitored the impact to ensure people did not experience adverse effects. For example, one person had their pain relief reduced, and staff closely observed them to ensure they did not experience discomfort. This showed a proactive and responsive approach to medicines management.