Hollybank Nursing Home

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 requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was previously in breach of legal regulation in relation to governance at the service. At this assessment we found improvements had been made and the provider was no longer in breach of this regulation, however further work was required to ensure these improvements were embedded and sustained

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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. We found the management team passionate about delivering person centred care. Staff and people’s relatives consistently told us how they found the management team approachable and available. One relative told us, “I have spoken to [registered manager] many times and they are doing a great job.” A staff member told us, “The managers are kind and helpful, they have the interests of the residents at heart, they get involved and are always around.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt confident in raising any concerns and trusted that any issues raised to the management team would be taken seriously and acted upon. The provider had a whistleblowing policy in place and staff were aware of this. Staff knew how to raise concerns outside of the service to relevant authorities.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes. Whilst we found some improvements had been made following our last inspection, we found further work was required to ensure the governance of the service was effectively managed. Audits had not been used effectively to identify the shortfalls we found in relation to window restrictors, fire alarm and emergency lighting checks. The registered manager took immediate action to rectify this, however this process needs to be embedded and sustained. We found systems and processes were in place to ensure policies and procedures were up to date and risks to people in respect of their needs were now mitigated and effectively monitored.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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. The provider had taken many steps to improve the service following our last inspection, this included implementing a digital care record system which had improved the way in how staff recorded, monitored and actioned people’s health and wellbeing needs. The provider also shared with us their action plans to refurbish the environment.