Archived: The Hollies

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 inspection we rated this key question good. At this inspection the rating has changed to inadequate. This meant the service was not well managed or consistently well-led. Leaders and the culture they created did not always promote high-quality, person-centred care.

This service scored 36 (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 did not always have a clear shared vision, strategy and culture.

The registered manager did not have a service guide to share with people, relatives or staff. Whilst the registered manager felt the service offered a ‘homely environment, gardens and pets to spend time with’ this had not been put into any accessible information or developed into a shared vision for the service.

No training, developmental opportunities or supervision was offered to volunteer staff to ensure a culture, based upon the registered manager’s hopes for the service, was developed.

No effective systems or processes were in place to monitor the quality and safety of the service to identify where improvements were needed. Effective systems and processes may have enabled the registered manager to develop a shared direction within an improvement plan for the service.

The provider did not always have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

The registered manager did not always have the skills, knowledge and experience to provide effective support and guidance to the volunteer staff. They failed to maintain oversight of the quality and safety of care being provided. Systems and processes were not in place to ensure effective checks on the quality and safety of the service were completed, as they had not identified the issues we found. For example, a pack of out of date medicine was in the medicines cabinet and should have been removed and safely disposed of as soon as out of date.

The registered manager had not refreshed their skills and knowledge to ensure best practice was consistently followed. They had not offered core or specific topic training to volunteer staff.

Despite operational shortfalls, the volunteer manager told us, “The registered manager and me work well together supporting people living here’. And a relative told us, “The manager treats the people living there as she would her own children.”

The provider did not always foster a positive culture where people felt they could speak up and their voice would be heard.

A volunteer shared with us that the registered manager was ‘not always open to changes’ and ‘liked things as they were’ and the registered manager agreed with this. This meant that when ideas about where improvements could be made were shared, these were not always explored.

However, relatives felt they could contact the registered or volunteer managers if they needed to discuss anything.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We assessed this quality statement against how the volunteer workforce were valued by the registered manager, as they do not employ any staff.

Improvements were needed to ensure volunteer staff were offered training, developmental opportunities and supervision to ensure a fair culture.

The volunteer manager told us they felt ‘happy’ volunteering at the home.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems at the service were not robust and governance failures were evident across multiple areas of the service including fire safety, medicines management, recruitment arrangements, training, environmental safety and care planning. These concerns had either not been identified or had not been acted upon despite previous feedback from the local authority. This demonstrated governance systems were ineffective and unable to drive sustained improvement.

The registered manager told us they undertook informal checks in the home, but we found these had not identified the shortfalls we found during our visit. For example, informal checks on the safety of the environment had been ineffective and hazards and risks to people remained present.

The registered manager had no policies and procedures in place, had not undertaken training and told us they did not link with any external organisations to ensure they kept up to date with current best practice and guidance. This impacted the registered manager’s resources and skill set to monitor and improve the quality and safety of the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. However, they did share information and learning with healthcare partners to ensure people achieved positive outcomes.

Improvements were needed in how the registered manager worked with the local authority to ensure their feedback was acted on in a timely manner to drive forward the required improvements.

The registered manager shared examples with us of information they had shared with healthcare professionals, so services worked effectively for people. For example, 1 person’s health scan had showed a change, and the registered manager was supporting this person in attending specialist appointments and sharing details of their wellbeing as needed.

People were involved in planned outings in the community and accessed numerous venues. For example, 1 person enjoyed going to the hairdressers.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Learning systems at the service were ineffective, where opportunities to learn from external feedback, best practice guidance and partner agencies had not been fully utilised. As a result, improvements identified by others had not been implemented in a timely manner and opportunities to improve outcomes for people had been missed.

The registered and volunteer managers told us they had received feedback from the local authority, following their visit earlier in the year, identifying where some improvements were needed. For example, in volunteer staff checks and in undertaking training. However, we found actions had not been taken to make these improvements.

The lack of effective checks on the quality and safety of the service meant the registered manager missed opportunities to learn, improve and innovate the service.