- Homecare service
Holmwood Gardens Domiciliary Care Services
Assessment report published 1 September 2025
Contents
Ratings
Our view of the service
Date of inspection 7 July 2025 to 25 July 2025. The inspection was prompted due to concerns received about safe care and treatment and a lack of effective management oversight. Concerns related to poor staff practice, medication management and safeguarding concerns.
Holmwood Gardens provides personal care for people living in their own tenancies. The service provides support to autistic people and to people with learning disabilities. At the time of our inspection there were 18 people receiving a regulated activity under the registered location.
We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
People had progression plans in place to develop new skills and experiences which staff supported people to achieve. Relationships which were important to people were developed by staff teams to maintain important connections with family and friends.
We identified under the key questions Safe and Well Led the service was in breach of legal regulations in relation to safe care and treatment, safe and effective staffing and good governance.
Risk management in relation to how individual’s emotional and behavioural needs were assessed, planned for and mitigated were not sufficiently robust and at times meant people were not safe from potential and actual harm. People with acute health conditions did not have their health needs managed safely. Staff were not always deployed to meet people’s needs. They also lacked training, skills and knowledge to support people effectively to manage distressed behaviours and specific health care tasks. Incidents were not managed or reported in line with the provider’s policy.
Leaders of the service did not have effective oversight, knowledge and understanding of people’s behavioural and emotional needs and the management of incidents was poor and did not lead to a culture of learning and improvement.
The provider was previously in breach of legal regulation in relation to good governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
Despite the concerns found at this inspection, we received positive feedback from people and their relatives who all told us they were happy with the care and support people received. Comments included, “I am very settled here, and I do feel safe. Staff help me and take me out doing the things I like” and “I thought the other place was good, til [person] moved here. It is immaculately clean. Has 24/7 care. their smiles say it all”
We observed staff interacting with people to assess whether they received good care. Some people could not directly tell us about their experience. This approach showed most staff knew people well, however, we observed, and staff told us they lacked specific skills and training to ensure they could communicate with people in their preferred way. Therefore, we could not be assured that all people receiving this service were enabled to share their feedback in a meaningful way.