Holistic Care UK

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 this inspection the rating is Inadequate. This meant people were not safe and were at risk of avoidable harm

We found the provider to be in breach of 1 legal regulation relating to governance.

This service scored 36 (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 always demonstrate a culture of learning and improvement or show how this was being embedded into the service to ensure people received safe, high-quality care.The provider carried out surveys and engaged in regular conversations with people, relatives and staff. However, it was not always clear and there were no records to show how their feedback was being used to improve the service provided.

The provider failed to ensure legal regulations were being followed. We identified breaches of regulations which placed people at risk of harm.

The relative we spoke to told us they knew who the manager was, and they felt able to approach them. Despite the positive feedback, aspects of the service were not well led due to the lack of systems and oversight which failed to ensure people received care from competent staff at all times and clear person-centred records were in place.

Staff told us they knew how to speak up if they had concerns or something went wrong. However, there were no systems in place to support open and transparent ways of working. Although the service had policies in place, there were no systems to formally capture the views of staff. The provider was unable to demonstrate how they listened and responded to staff when concerns were raised.

Staff felt well supported in their job roles. They told us the registered manager were supportive if they had questions about their job roles. They also told us they could request extra support if needed.

The provider did not have an adequate understanding of their role and lacked effective oversight of the service. The provider was not aware of the issues we found at this inspection and did not provide evidence to demonstrate how the service was well led. The lack of systems to monitor the quality of the service and provide effective provider oversight did not allow for lessons to be learnt. There was no evidence action was taken to drive improvements in the service. This placed people at risk of harm.

The provider’s monitoring and governance processes were not sufficiently robust. The provider’s systems to identify and manage risks were not effective, as they had not always identified the risks people faced while receiving care and had not always put effective risk management plans in place to address mitigate risks. People’s care plans did not include all relevant information about their specific health conditions and how they impacted them as individuals and updates to people’s care needs were not always recorded.

The systems to ensure people always received their medicines safely were not always effective, as we identified shortfalls with the way the provider was managing people’s medicines, which placed people at risk of unsafe care.

The provider carried out audits for care plans, medicines management, dignity and infection control. However, audits for care plans, medicines management, and dignity audits were ineffective as the provider failed to identify the shortfalls found at this inspection.

We did not find the provider to be open, honest and transparent. The provider failed to inform us that they were moving and would be operating the service from an unregistered location. The provider also failed to provide us with information we asked or if it was it was not done in a timely manner.

People’s care plans were not always up to date, detailed and accurate, therefore it was unclear whether partnership working was always fully supporting safe care. Evidence we collected did not demonstrate the provider understood their duty to collaborate and work in partnership with other services to ensure continuity in people’s care and to achieve the best outcome for people using the service.

We saw no records to demonstrate the provider did not focus on continuous learning, innovation and improvement across the organisation. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe and effective practice.

We found serious failures in the service's governance, oversight, and leadership that did not ensure safe, effective, caring, responsive or well-led care. The systems in place did not support the effective assessment, monitoring, and mitigation of risk to people’s health, safety, and welfare. This did not support a culture of openness and learning within the service.

The lack of any analysis of feedback received from people, meant this information had not been used to make improvements across the service and people were being placed at risk of receiving a poor quality of life due to a lack of continuous learning and improvement.

Regular care staff meetings were held, however, the opportunity to learn from organisational learning and sharing of best practice in relation to individuals had been missed.