Holywell Nursing 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. This was the first assessment for this service under the new provider. At this assessment we have rated this key question 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 management team had a shared vision, strategy and were developing a more positive and professional culture. This was being based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The management team had made many improvements but were keen to keep improving the quality of the service as they accepted they were “Not where they wanted to be as yet.”

The management team had introduced a more positive and open culture, but this was still being imbedded. People and relatives gave many positive comments about the home including, “I am well pleased, the staff are very good” and “I am happy here, my son got me the best place.” Some people described a less positive culture. One person said some agency staff could be “extremely lazy, and unkind to residents.” They told us when they raised this with the manager these staff were not employed again at the home.

The environment needed improvement and there were some malodours on the first-floor landing. Equipment such as bed rail protectors were in poor condition until this was raised during the inspection and promptly addressed.

All staff spoken with told us they were keen to provide the best quality of care and support to people as they could. Staff told us the “Staff team get on really well” and the “New structure works better; staff have clear roles.” Several staff described the manager as “Approachable and friendly” and said they would recommend the home.

The management team were all inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

The manager was a qualified nurse and led by example. People, relatives, and staff were complimentary about how the management team ran the service and the improvements they had made. They were driving improvements in a compassionate and inclusive way.

Staff spoke positively about the new management team. Staff told us the manager and deputy were visible, supportive and worked alongside them, and that communication and feedback across the team had improved.

The management team were open and keen to learn. The manager told us they were “Really glad” we had visited as they wanted to know they were “On the right track.” When we identified concerns, the management team took immediate action to rectify these and began wider audits in response.

There was a clear improvement plan. The management team were honest that the service was not yet where they wanted it to be but were committed to continual improvement.

The management team had developed and fostered a positive culture where people felt they could speak up, and their voice would be heard. People, relatives and staff told us they felt confident to raise concerns with the management team and these would be listened to and acted upon.

There were now formal meetings with people who lived in the home to gain their feedback. Staff spoke with people on a 1 to 1 basis if they could not attend the resident’s meeting to ensure their views were heard.

Relatives and staff felt able to raise concerns and were confident they would be listened to. Staff told us they would report concerns to their line manager and, if not listened to, knew they could go directly to the local authority safeguarding team or CQC. One staff member said, “If I saw someone doing something wrong, I would address it with them,” and described being aware of whistle blowing routes.

Staff described raising concerns about staffing levels and told us they were listened to and staffing increased. People and relatives confirmed they knew how to complain and felt issues were taken seriously and acted upon. One recent serious complaint about 1 staff member had led to the staff member being investigated, dismissed and referred to their professional body. One person told us when their family had highlighted an issue, “It was dealt with quickly.”

Any compliments about the home or staff were recorded. One relative had said their family member had been, “Looked after so well.” Another person commented, “Lovely stay. The staff were incredible attentive and friendly. I would absolutely recommend this home."

Staff felt valued, treated fairly and supported to develop. One staff member told us, “I do love working here,” and said they felt they were being treated “equally and fairly.” Staff reported no concerns about discriminatory treatment towards themselves or colleagues.

The management team had implemented staff supervision, probation reviews and appraisals, which helped ensure performance and development were discussed regularly. Staff in different roles described opportunities for progression.

The management team promoted an inclusive culture where staff felt able to contribute ideas and feedback. Staff now felt “Valued and empowered to contribute ideas” and that an inclusive and fair culture was being embedded.

Governance and management systems had significantly improved under the new management team but were not yet fully effective or embedded. They had introduced structured quality assurance processes, regular audits and developed an improvement plan, which helped to hold staff to account and monitor the quality and safety of the service.

However, some checks were inconsistent or not identifying issues. We found care plans were not always sufficiently detailed or personalised and that important plans, such as skin integrity and pressure ulcer prevention, were missing for a newly admitted person at the start of our visit. These were completed during the inspection. Some pressure mattress settings and bed rail protectors were not correctly set or maintained until inspectors raised this with the manager.

Recruitment, training and staff supervision processes were better organised and enabled leaders to monitor staff performance and support. One staff member told us, “There was no structure for staff at all before. It was a free for all.”

A relative’s survey and a staff survey had been carried out during October and November 2025. The responses were mostly positive with comments such as, “Lovely staff, amazing atmosphere, great management and admin” and “Atmosphere is so much better. Keep it up.”

Relatives had commented in their survey, “Improve the home, it is looking tired”, and “More decoration and better flooring [was needed].” Environmental refurbishment was underway, but many parts of the home remained worn. The management team acknowledged the home needed further work and were using audits and action plans to drive and monitor improvements.

The service worked well with families and external professionals to support people’s care. Relatives told us they felt informed and involved, and GP’s advice and changes to medicines were communicated back to them. People and relatives said they knew the manager and found them approachable if they had concerns.

Staff worked with GPs, pharmacists and specialist teams such as tissue viability nurses and occupational therapists to meet people’s needs. The medicines lead nurse explained they liaised regularly with the practice‑attached pharmacist and requested medication reviews when needed. Although the local GP surgery was reluctant to see people in person, staff escalated concerns and used phone and email contact to obtain advice and additional medicines if these were needed.

People were supported to maintain relationships and be part of the home community. Visiting was open, and people described being able to see family when they wished. There were examples of social events, such as celebrations for Chinese New Year with an entertainer and buffet, and residents being supported to go to the local shop or pub in better weather.

The management team were clearly focused on continuous learning and improvement across the organisation and local system. They wanted good outcomes and a good quality of life for people. They were developing safe and effective care practices.

The management team used information from feedback, audits, complaints, incidents, and safeguarding alerts to improve the service. They worked with staff to understand what happened if things went wrong and involved them in finding solutions to prevent recurrence.

Discussions with the management team and staff demonstrated they recognised the importance of learning lessons and continuous improvement to ensure people received care and support that was safe and effective. Both the management team and staff team welcomed advice from the inspection team and confirmed that our feedback would be used to further develop the service. This showed there was a commitment to embed a culture of continuous improvement.