Holland 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 requires improvement. This meant the service was managed and well-led. However, shortfalls were found in the recording and governance systems in the service. More work was needed to ensure effective governance and oversight processes were in place.

This service scored 62 (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 management team championed a culture of openness and honesty which was mirrored by the staff team. Staff spoke passionately about how they provided good care and how they all had a shared goal across the organisation. A staff member commented, “It is a good team, we all work well and have the same goal. To make sure people have the best life they can have.” While another staff member told us, “Overall we are working to support people to have a better life.”

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.The registered managers and the senior leadership team were knowledgeable about their roles and had the experience needed to ensure the care provided was of a good standard. They were open to feedback from people and acted on any issues brought to them. A family member told us, when asked about the managers, “They are very approachable, any questions I’d not hesitate to contact staff and the manager. The manager is very helpful. Any concerns I’d not hesitate, they’re great.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.Managers lead with an ‘open door policy’ which meant people, staff and families could approach management at any time if they had any concerns.The opportunity to speak and share views was offered within the staff meetings with managers taking on board people’s comments and acting on them when needed. People were actively encouraged to discuss their care within regular house meetings. Staff supported people to feedback on what mattered to them so positive changes could be made.

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.There was an inclusive and fair culture with equality and equity for staff. All staff were positive about working at Holland House and felt they were treated with respect.

The registered manager had oversight of the service and was onsite daily to offer support and governance, however the recording of this oversight lacked consistency. Staff and managers could tell us additional checks were taking place to ensure the care provided was to a good standard, however these were not always recorded. For example, the registered manager told us they completed night checks but there were no records of this. Governance systems needed improvement to provide a more robust system of oversight for quality, safety and care. Audits were taking place; however, we found that these were basic in detail so were not always an effective check of standards. Managers who provided a second check to audits did not pick up when a mistake was made. For example, the personal allowance audit showed an error in the record, this was signed by a senior leader as complete, but action had not been taken to review the error made and this was not picked up by the second manager who checked the record. Care plans had not been formally audited; we found some care plans had missing information, such as, missing finance care plans, but the need for these care plans had not been highlighted by the care plan audit completed by the registered manager. Other checks taking place did not always happen when they should and the areas checked varied from each record. For example, the personal allowance audit was not completed monthly as expected, the IPC audit did not always review people’s bedrooms and the walk round audit did not give clear guidance on what areas needed review. People had not been affected by the inconsistent recording of quality checks, and we saw that people received a good standard of care, however the service would benefit from formalising its governance structure and auditing tools to clearly evidence the oversight managers have. The registered manager was open to feed back at the time of the inspection. They took comments onboard and as an outcome of the inspection they began implementing a more robust auditing structure to fully evidence the governance.

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. Strong relations had been made within the community which helped improve people’s access to new opportunities. Best practice was shared across other partners, sharing knowledge and working collaboratively to review care and improve.

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. However, more work was needed to clearly evidence learning from incidents. The registered manager had oversight of the accidents and incidents within the service. However, it was not always clear if staff had learnt from when things went wrong or if they had been given the opportunity to reflect and review their actions. Records needed to be more robust to show continuous learning. The registered manager took onboard our comments at the time of the inspection.