Holcroft Grange Residential 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 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although the provider fostered a culture which was based to provide high-quality person-centred support and care to people, this was not always as effective in practice. For example, although people were positive about the care they received from staff, people’s care plans and daily records were not completed sufficiently meaning there was a risk people’s needs and challenges may not be fully understood or met by staff.

However, the culture of the service was positive in terms of staff interaction. Staff told us it was a nice place to work and that the provider was supportive and responsive. The manager interacted with people, their relatives and staff at every opportunity and the atmosphere in the home was relaxed, stimulating and homely.

We could not be assured leaders understood the context in which the provider delivered care, treatment and support and always embodied the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge and experience to lead effectively.

At the time of our inspection, a new manager was in post and had applied to CQC to become registered. The new manager was supported by the provider, but the service had not been led as effectively as it should. For example, governance tools and audits and processes had not always been effective at providing oversight to help deliver safe carer and we identified shortfalls in how risks were identified and managed.

However, we received positive feedback about the manager from people, relatives and staff. People told us, “[Manager’s Name] is very kind and thoughtful and what I like is that she listens. If I get upset, I can talk to her about personal things, and she says her door is always open. She is very good at reassuring me” and “[Manager’s Name] is warm and friendly, and she always says good morning to me.” A relative shared, “[Name] is the manager - she seems very personable.”

Since the manager had taken on their position in the home, they had identified areas which required some improvement and had devised new and improved governance tools which were better adept at identifying and mitigating risks. However, further time was required to allow these new processes to become embedded. The manager had a visible presence in the home and adopted a hands-on approach. They carried out visits during the weekend and at night-time to ensure they maintained a relationship and had oversight of night and weekend staff.

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

The provider had processes in place to gather people’s feedback, such as resident meetings and questionaries. We also observed a ‘You said We did’ poster. We saw how changes had been made in direct response to people’s feedback. For example, about people wanting a Continental breakfast as an alternative to a full English. People told us about other changes which had been made, one person said, “Supper used to be a drink and a biscuit, and things were said, now we have crumpets, cakes or toast which is better!”

People’s feedback was analysed and considered. Opportunities to act on people’s feedback and potentially enhance their experience of the care they received were acted on. Relatives also told us they had opportunities to speak up. Comments included, “If there was anything wrong, I could tell them” and “They do have meetings, and I go when I can.”

The manager told us they had an open-door policy and were available to people, relatives and staff at any time.

Staff told us they felt able to speak up and raise any concerns relating to the service, people’s care or their own employment. One member of staff told us, “The managers always listen to staff concerns and encourage open communication.”

Safeguarding and whistleblowing policies were in place to guide staff on how to raise and report 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.

Processes were in place which helped to protect the rights of staff under the Equality Act. Risk assessments and any reasonable adjustments measures were used if appropriate. This helped to create a more equitable and inclusive organisation.

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.

The home’s management and leadership required improvement. The provider failed to adhere to ensure processes were robust and reliable enough to ensure safe and appropriate care.

Risk to people had not always been assessed correctly, as risk assessment tools were not reliable or robust as they should have been. This meant people were potentially exposed to a risk of harm as their risks had not been properly managed and mitigated.

Some legislation in relation to people’s care was not understood or properly implemented. For example, mental capacity and deprivation of liberty legislation.

Although processes were in place to enable a range of regular audits to monitor the quality and safety of the service provided at the home, they were not always being completed. For example, we could not trace any auditing of people’s care plans.

This meant that there was no evidence that the provider had proper oversight with regards to people’s care plans or how they monitored the quality and accuracy of them to ensure they provided accurate, consistent and up to date information, for staff to follow. This meant opportunities were missed to help drive up improvements in care planning, care delivery and the best possible outcomes for people.

For people on regular welfare checks, the time between some checks exceeded what was recorded as being required in people’s care plans. We could not be sure if these inconsistencies in people’s care records were record keeping failures as opposed to shortfalls in the delivery of care and support.

Other information in relation to people needs was also insufficient, for example personal evacuation information.

This meant shortfalls in practice in the safety and quality of care and actions for improvement could be missed.

Medicines audits were completed and had identified shortfalls we identified in August 2025. However, at the time of our inspection, action had still not been taken to address.

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.

As the processes used to assess risks to people were not always reliable, there was a chance information which ought to be shared to external partners, for example, such as the Local Authority, may not have been, meaning opportunities were limited to share information and best practice.

However, we saw examples of how the manager had sought help and support from external services where appropriate, to ensure people received the support they needed.

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.

As the provider did not have reliable processes in place to assess risks to people, they did not have an accurate picture of risk across the service at any one time. This meant opportunities to learn from any shortfalls in practice and to make the necessary improvements may have been missed, and better outcomes and experiences for people may not have always been achieved.

However, we discussed the issues we had found during our inspection with the registered provider and manager found they were receptive to our feedback. They had already identified some of our concerns and had begun to work on implementing actions to resolve the shortfalls. It was clear the new manager was passionate and committed to their new role and genuinely cared for the people they helped to support. This demonstrated a positive commitment to achieving improvement in standards of care and support moving forwards.