Holly Lodge

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.

This is the first assessment for this service since its registration under a new provider. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had moved from their previous provider to a new provider a year ago. There had been a period of transition for leaders and staff at the service, including a change of roles and responsibilities for some. Other changes included different training systems and policies and procedures. Staff we spoke to knew what the objectives of the provider were and felt the provider’s culture was good.

The service building needed updating. The provider had audited the service and had identified the necessary improvements. This included replacing kitchenettes, flooring and boilers for heating and hot water. They had a plan to ensure these were completed within the next year. The provider had shared this plan with leaders and staff.

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.

The registered manager and other managers at the service and been in post for several years. They had good oversight of the support needs of people and were able to ensure support for people was delivered in a caring way. Staff told us leaders were caring and approachable. They listened to staff when they wanted to discuss things with them. One member of staff said they had made a very positive impact on their own wellbeing by supporting them to sustain their employment during a difficult period in their life. Managers spoke of people and staff in a compassionate way and demonstrated they considered both people and staff wellbeing.

There was a new area manager who was employed by the new provider. They had spent time at the service to get to know people and staff. Leaders had identified 1 person had a high level of support needs that were not being met by other professionals, they had arranged for some experts within the company to support leaders to ensure the person had access to specialist support.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People, their families and staff all told us they felt they would be listened to if they raised any concerns with leaders.

Staff told us leaders, including care leaders were approachable and they felt confident they could raise issues both within formal supervision and in informal meetings. The provider had a speaking up policy.

When there had been shortfalls raised to the registered manager, they had taken appropriate steps to address the concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a diverse workforce within the service. Staff told us they felt the were supported well by leaders in relation to their diverse needs. This included providing a prayer room for those staff that needed to pray during their working day. Leaders told us what steps they had taken to support the workforce in an equal and inclusive way.

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, or share this securely with others when appropriate.

Audits we reviewed were generally effective, for example the fire and IPC audits, however medicine audits had not identified the shortfalls inspectors found during the inspection. For example, audits stated that fridge temperatures were regularly being taken but inspectors saw this was not the case. Further shortfalls inspectors identified relating to PRN medication had not been identified in management audits. This meant leaders could not be assured medicines were always administered appropriately and in line with current national guidelines.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Leaders and staff told us they worked in partnership with other professionals. Professionals we spoke to confirmed this. One professional said the service was very proactive in ensuring they worked in partnership with all the professionals that were involved in the care and support of people. this ensured the best outcomes for people.

We saw in people’s records that they were supported following the guidance given by other professionals.

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.

The provider could not demonstrate all staff were up to date with their mandatory training. Leaders explained this was because they were transitioning to a new training system and could not access the previous one. Furthermore, they had not ensured that staff had received mandatory training in learning disability and autistic people. This has been mandatory since September 2025. The provider had a plan to deliver this training, but it was not going to be compliant until 2027. Because the service was a specialist learning disability service staff had training that was the equivalent to the mandatory learning disability training which meant the lack of mandatory training was not an significant issue.

There was a process for recording and reporting incidents. Leaders explained how they would review incidents to learn from them and to reduce risks of incidents happening again.