Hollyveer 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 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 service under the current provider.

This key question has been rated 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 provider was in breach of legal regulation in relation to the governance of the service.

This service scored 54 (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 promote a clear shared vision and culture for the service. We received mixed feedback from people, relatives and staff about how well the provider engaged with them and sought their feedback to shape and improve the service. Processes for demonstrating how learning and improvement were embedded into the service were not robust. The provider did not have a clear strategy or action plan to address areas where improvements were needed.

Leaders were not always able to demonstrate a robust understanding of the issues and priorities for the service. Where concerns were identified during the inspection, the provider was not always able to demonstrate they were aware of these concerns or evidence how these issues were being prioritised and addressed. At the time of the inspection, the registered manager was responsible for the oversight of 2 other services and their time was split between these different services. We received mixed feedback from staff about the visibility and accessibility of the registered manager in the service.

Staff told us they were able to speak up and there were policies in place to support this. However, we received mixed feedback about how well the provider listened and responded to issues raised. This meant staff did not always feel their voices were heard.

The provider supported inclusivity in their workforce. Policies were in place to ensure equity in their recruitment and training opportunities. Staff told us they were able to request any additional training they required to fulfil their role.

The provider’s governance processes were not effective. The provider was not able to demonstrate clear oversight of risks to people’s health and safety. Audits completed by the management team had failed to identify and address the concerns we found with people’s care planning, risk assessment and capacity assessment documentation. The provider was not able to demonstrate robust oversight of risks relating to the safety of the environment and infection prevention and control. Systems were not in place to ensure robust management of feedback, concerns and complaints to ensure the necessary improvements were made.

The provider understood their duty to collaborate and work in partnership with other health and social care professionals. We received generally positive feedback from the health professionals who worked regularly with the service. Comments included, “They are very quick with their assessment and admissions process”, “My experience of this provider has always been positive” and “The staff are always on hand, polite and provide relevant information.”

The provider did not always focus on continuous learning, innovation and improvement. Whilst management checks were in place, these were not being used effectively to monitor and address ongoing risks or identify areas where the service could be developed and improved.