Holme House Care 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 good. At this assessment the rating has changed to 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 in breach of legal regulation in relation to governance at the service.
 

This service scored 46 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.
There were some positive indications that leaders were open and honest and were taking steps to address the quality and culture within the service. Staff meeting minutes showed concerns were discussed, and leaders had made efforts to engage staff and reinforce organisational values, including provider level input at meetings to set expectations around standards and behaviours.

However, this had not yet translated consistently into day-to-day practice. Staff were not always working in line with the organisation’s values, and there remained a gap between the direction set by leaders and the culture experienced within the team. Staff told us they wanted to provide good quality care but described barriers such as high workloads, and perceptions of inequity in team contributions. As a result, the culture across the service was not yet fully embedded and required further development to ensure consistency.
 

Leaders demonstrated the skills and integrity required for their roles; however, improvements were needed to ensure consistent visibility, effective follow-up of concerns, and a more uniform experience of support across the service.

Leaders demonstrated appropriate experience and knowledge to carry out their roles, and we saw examples where honesty and integrity were applied, particularly when responding to complaints and conducting staff investigations.

However, feedback from staff indicated leadership visibility was not consistent. Staff told us managers were not always present within the service, which impacted on how supported they felt and limited opportunities to observe leadership in practice. Responses were mixed regarding the level of support provided, indicating inconsistency in how leadership was experienced across the team.

We also identified that follow-up to some concerns was not always clearly evidenced. For example, where issues such as unexplained bruising had been identified, there was not always clear documentation to demonstrate timely or consistent action.

People using the service and their relatives were not always aware of who the registered manager was. One person commented, “A new manager started 2 weeks ago, they haven’t introduced themselves yet.” A relative shared, “There is a new manager, I don’t see them much, I have not been introduced,” and “I thought the manager was [previous registered manager], I don’t know anything about [new manager].”

Overall, while leaders demonstrated capability, improvements were required to ensure consistent presence, follow-up, and engagement.
 

People did not always feel they could speak up and that their voice would be heard.
Systems were in place to support staff to raise concerns, and staff were aware of the processes available to them. Leaders had communicated the importance of reporting concerns and poor practice.

However, the culture within the service did not consistently support staff to feel confident in using these systems. Some staff told us they would feel hesitant to raise concerns, particularly in relation to safeguarding or colleagues’ practice, due to fears of not being believed or potential negative consequences.

This indicated that whilst processes were in place, they were not fully embedded in practice, and there was a risk that concerns may not always be raised in a timely way, which could impact on people’s safety and wellbeing.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Recruitment processes appeared fair, and the staff team reflected a diverse workforce. Staff had completed training in equality and inclusion and told us they felt able to recognise and respond to discrimination where required.

However, some staff feedback suggested inconsistencies in how concerns about colleagues were managed. A small number of staff felt when they had raised issues, these were not always handled in a way they perceived as fair, and in some cases, they felt misunderstood.

This indicated that while policies and training were in place, further work was required to ensure all staff felt confident that concerns would be managed consistently, fairly, and without bias.
 

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 and processes were not consistently effective in identifying shortfalls or driving improvement. Although a range of audits and monitoring tools were in place, these were not always used effectively to provide clear oversight or ensure risks were acted upon.

We found audits did not consistently capture key risks or provide sufficient analysis to inform action. For example, the Waterlow audit was in place; however, it did not clearly link to whether repositioning was being carried out for those identified as high risk of pressure ulcers. Medication audits were ineffective and had failed to pick up on the issues found on assessment. Call bell audits had been completed but failed to identify multiple bedrooms did not have call bells in situ or in reach. This presented a gap in oversight.

Monitoring processes, including those relating to care planning, nutrition, risk assessments and incident records, were not always aligned or accurate, which limited their effectiveness in identifying concerns. We saw limited monitoring in place for behavioural incidents or recording,, fluid intake and repositioning records. Although care plans were subject to monthly review, these reviews were not always accurate, and in some cases, identified inaccuracies remained despite the use of ‘resident of the day’ processes.

Provider-level audits indicated care plans for new admissions should be completed within 7 days; however, we identified an example where this had not been achieved, suggesting inconsistencies in how this process was implemented and recorded.

A service improvement plan was in place; however, actions had not always been completed within expected timescales, and some shortfalls remained despite being identified over a prolonged period. This included areas such as care plan accuracy, use of monitoring tools, and completion of assessments. This indicated that whilst areas for improvement had been recognised, there was not always effective follow-through to ensure sustained progress.

Overall, governance arrangements did not provide sufficient assurance that quality and safety were being effectively monitored and improved.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.
The service had established some links with external organisations, including involvement in a veterans’ friendly scheme, which was positive. Additional partnership working was in place with Kirklees and Calderdale Care Association and independent trusted assessors, demonstrating engagement with sector support networks. However, there was limited evidence of strong or sustained links with the wider community. Opportunities for people to access community-based activities remained limited, although some individual examples of people being supported to go out locally were observed.
Partnership working with healthcare professionals was evident, with input from GPs, dietitians, district nurses and other professionals recorded within visit notes. However, this information was not always consistently reflected within care plans. As a result, staff may not always have had easy access to up-to-date information about people’s needs without reviewing multiple records, which could impact on continuity of care.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There was limited evidence that learning and innovation were consistently embedded within the service. While systems for recording information were in place, these were not always used proactively to review practice, identify trends, or drive improvement.

We did not see clear evidence records, such as daily notes, repositioning charts, fluid intake or behaviour records, were routinely monitored as part of quality assurance processes.

Audit and governance processes were not consistently used to support reflective learning, and there was limited evidence that findings from incidents or monitoring were translated into improvements in practice.

The service held external accreditations, such as end of life accreditation. However, this had not been embedded into day-to-day practice or used to influence care delivery.

However, the service had gained a veterans’ friendly framework certification, and although this was in its infancy, the service had started to arrange networks for support in embedding this within the service.

Overall, while there were systems and frameworks in place, these were not yet being used effectively to support continuous learning, innovation, or sustained improvement across the service.