Holme House 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.
At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to safeguarding people and good governance at the service.
 

This service scored 50 (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 systems in place to record and analyse accidents and incidents; however, actions identified through this analysis were not consistently embedded or followed up in practice. There were inconsistencies in recorded which reduced opportunities to identify trends, learn from events and strengthen practice.

There was limited evidence that learning from incidents, accidents, and falls was consistently embedded into practice. While incidents were recorded, there was not always clear follow-through in reviewing actions, monitoring outcomes, or using findings to improve care.

For example, some audits relating to falls, identified actions, such as the need for staff to record behaviours prior to falls to help identify patterns or triggers. However, these actions were not completed. This meant opportunities to analyse incidents and reduce risk were missed. In another example, a crash mat had been identified as required following a person’s fall from bed, but this was not in place at the time of our assessment.

Safeguarding concerns were not always recognised or recorded consistently as incidents. For example, incidents of verbal abuse between service users were not always identified as safeguarding events. This limited the provider’s ability to respond appropriately and learn from such incidents.

Overall, although most incidents were recorded, oversight of actions from audits was not robust, so improvements were not reliably implemented or reviewed and opportunities to improve care and safety were missed.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Pre- admission assessments were completed and contributed to the development of care records. Information was also appropriately shared between professionals when individuals accessed external services.

However, systems in place to assess needs and share information were not always effective in ensuring that high-risk care needs were consistently planned, documented, monitored, and reviewed in a timely manner. Some care plans did not fully reflect assessed needs or show how care was being met. For example, 1 individual who required repositioning every 4- hours did not have corresponding monitoring of records in place to evidence this was being completed. In addition, although this person had been identified as being at the end of life on their assessment, there was no documented end-of-life care plan in place to guide staff in meeting their needs.

The pre-admission policy contained only basic information and did not set out clear timeframes for the completion of care plans and risk assessments following admission. This created a risk that people’s needs were not assessed and documented in a timely and consistent manner.
 

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

A safeguarding log was in place which recorded safeguarding events, and showed some referrals had been made where appropriate. The safeguarding file was up to date in terms of recorded activity.

However, staff did not consistently identify or record safeguarding concerns in practice. Incidents of emotional abuse observed during the assessment, such as 1 person shouting and being verbally abusive towards others, were not always recorded or appropriately addressed. This resulted in individuals being exposed to prolonged incidents of verbal abuse.

Records were not routinely completed in relation to behavioural incidents. As a result, there was no structured analysis of behaviours to identify triggers, patterns, or potential mitigations.

We identified concerns regarding the management of unexplained bruising and skin integrity issues. Across a 3-day period, 10 people were recorded as having new unexplained bruising or skin tears. Out of these 10 only 3 had investigations completed into their unexplained bruising. The remaining 7 people did not have documented investigations or recorded actions. We submitted a referral to the local authority safeguarding team on receipt of these findings, and the provider took action to review each of them accordingly.

We found the provider’s own safeguarding policy had not been followed in the delayed response to these injuries.
 

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Incident records were completed following falls and included whether the fall was witnessed and the immediate actions taken. Referrals had been made to the falls team where appropriate.

However, analysis of incidents was not sufficiently robust. For example, for a person who experienced 10 falls over a 2-month period, there was no clear analysis of patterns such as timing or location. Although an audit completed in January 2026 required staff to record behaviour prior to falls, this information was not consistently documented in subsequent incident records, and this gap had not been identified or addressed.

Care plans and risk assessments were not always updated to reflect significant incidents. In the case of the person with multiple falls, their falls care plan and risk assessments, updated in February 2026, did not reference the falls that had occurred between January and February 2026. This meant there was a lack of assurance risks were being effectively reviewed and managed.

Crash mats were not consistently in place where identified as required in care plans. During site visits, 2 people did not have crash mats in situ, although these were specified in their risk assessments. This was partially addressed during the assessment, however, inconsistencies remained in relation to their use throughout.

We also identified concerns regarding call bell systems. On the first day of assessment, multiple call bells were not plugged in. The provider’s audit processes had not identified these issues, indicating the audit system was not effective. This created a significant risk that people would be unable to summon assistance in an emergency. Although some improvements were made between days 1 and 2 of the assessment, discrepancies remained, including call bells not being plugged in or being positioned out of reach. The provider was taking action to rectify and monitor this.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service appeared homely, and people’s bedrooms were personalised. Environmental safety certificates and servicing records were in place. Personal Emergency Evacuation Plans (PEEPs) were available for all individuals.

However, there were issues relating to equipment maintenance and responsiveness to repairs. Some equipment was broken, and maintenance issues were not always addressed in a timely manner. For example, 1 person’s profiling bed was broken and remained in that condition for several days after being reported. This was escalated to management during the assessment. Other issues included broken bed parts and problems with sinks.

In addition, 2 fire doors did not close independently, presenting a potential risk to fire safety.
The provider added all actions to their service improvement plan.

 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.
The provider’s recruitment process was safe and fair. Training records were up to date, and the training matrix demonstrated staff compliance with mandatory training was good. Supervision arrangements were also in place, and staff management processes, including investigations and disciplinary procedures, were robust, fair, and consistently applied. A staff member was visible and present in communal areas at most times.

Staff told us overall there were enough staff on shift, and recent implementation of 2 seniors on shifts had been appreciated and helped support the staff team.
 

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.

Cleaning schedules were in place, and the home was well maintained to mitigate risks in relation to infection prevention and control. Domestic staff were visible and actively engaged in cleaning tasks across the home on both days of assessment, including high-touch areas.

Infection prevention and control (IPC) audits were completed, supporting oversight of hygiene standards. Overall, IPC practices were effective, and the environment was clean and hygienic.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Staff demonstrated good knowledge of people’s medicines needs and had received the required medication training and competency assessments. Staff administered medication appropriately on the day of assessment and we were assured with how staff were administering thickening agents to people’s drinks.

However, medicines records were not always accurate or complete in line with the provider’s own policy and national guidance. Key information, such as allergies and prescribed medicines, was not consistently recorded, and guidance for ‘when required’ medicines was not always in place or evaluated for effectiveness after administration. We also found gaps in recording, including the site of topical patch application, and occasions where medicines had not been administered due to unavailable stock. Although medicines audits were in place, these were not always effective in identifying or addressing issues, which meant risks to safe medicines management were not consistently mitigated.

The provider was responsive to the assessment findings and we found no harm had occurred to anyone as a result of the shortfalls in medicines management.