Holmhurst 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. This is the first assessment for this newly registered service. 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 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

Processes were in place to promote equality and diversity for people and the staff team.

The registered manager told us, “Our vision is, a home is a home. This is the people’s home, and we are part of the persons support system. We dress casually to fit in. We want the home to be comfortable and open. We as managers are like that and so we role model that to our team. CQC expectations are aligned with our values. We listen to people, talk to them, and explain what we are doing. Everybody makes mistakes, we want staff to come to us. Being open and honest.”

The provider’s values were shared with staff from the induction stage. When we spoke with staff, it was evident the providers values were instilled within them, because they spoke about the people they were supporting, with warmth and respect.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and strived to embody the culture and values of their workforce and organisation. Not all leaders had the skills, knowledge, experience, and credibility to lead effectively.

Prior to this inspection leaders had not independently identified and acted on concerns we found during this inspection. This meant some development was needed in their skills and knowledge to lead effectively.

Staff told us the registered manager was accessible and approachable. One staff member told us, “I can always speak to the registered manager if they are in work and if not, they are always contactable remotely. I can contact them 24/7.”

We observed all members of the management team shared the provider’s values and to be supportive to both people and staff and they were motivated to ensure the people living in the home were living their best lives.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

People living in the services were asked for their views and were given the opportunity to speak up daily, both informally, in meetings and through survey’s. The registered manager told us action plans were devised from these conversations. This meant people’s views were listened to and drove improvement.

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

Staff were engaged and felt empowered to work autonomously and with confidence. Staff were able to contribute to staff meetings and supervisions and were confident they would be listened to. Staff felt valued by the provider. There were policies and procedures in place which underpinned the importance of the fair and equitable treatment of staff and the well-being of the workforce.

The registered manager told us about the organisations flexible working policy which meant staff were supported to work flexibly around childcare, carers responsibilities and medical appointments.

The service had been operational for 5 months at the time of our inspection. The provider was still developing and embedding systems of accountability and good governance to ensure they could always act on the best information about risk, performance, and outcomes.

Although we observed audits were completed in relation to some areas such as Health and Safety, IPC, Water safety and Medicines. All areas relating to the operation of the service had not at the time of the inspection been comprehensively monitored. For example, incident review and statutory notifications had not been identified as an area that required improvement.

The provider shared with us their plans to complete an overarching quality assurance audit. Although there was confidence in the registered manager, they required time to identify actions, make changes, and embed them into practice.

Staff understood their roles and responsibilities. Staff and the management team understood the importance of reporting any changes to people’s wellbeing. They kept detailed records of the support people had received.

There were security measures in place to ensure all paper and electronic information was stored safely and securely by following the principles of General Data Protection Regulation (GDPR).

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff and the registered manager shared with us positive examples of collaborative working in partnership. The registered manager told us, “There is an online forum for local care home managers, we join these meetings and discuss concerns and solutions to issues we are dealing with. We subscribe to the local authority and CQC newsletters. As a provider we will read CQC reports from care homes within our communities.”

The service strived to focus on continuous learning and improvement across the organisation and local system. Although the provider was motivated to learn and improve the service for people, comprehensive internal audits needed to be completed over a period of time to ensure they would always be aware of shortfalls to enable prompt improvement and learning.

The provider was responsive during our inspection and told us they were taking learning from this inspection and would be sharing this across their organisation.

The registered manager shared with us several ideas of how they wanted to improve people’s experience, these included introducing new activities both inside and outside of the home, however, time was needed for these newly introduced practices to bring about the required improvements. Learning had also taken place, and the provider had strengthened their assessment process to ensure all information was known about people before a decision was made to accept a referral for someone to move into the home.