Holmwood Gardens Domiciliary Care Services

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Inadequate. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment and safe and effective staffing. Overall, there were enough improvements found at this inspection and the provider was no longer in breach of this regulation.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Since the last inspection, the registered manager has strengthened oversight by implementing more robust systems and processes. These improvements have supported the development of a positive learning culture, ensuring lessons from accidents and incidents were consistently identified, shared, and embedded into practice. This supported staff to reflect on what happened, understand how to prevent recurrence, and continuously improve the quality and safety of the support provided.

The introduction of ABC chart (Antecedent-Behaviour-Consequence, a tool used to understand behaviour) monthly analysis, and monthly accident and incident analysis was implemented and embedded by the registered manager. This oversight meant the management team could undertake timely updates, review care plans, and ensure lessons were learnt and actions were taken to improve care and keep people safe. The registered manager told us, “Since implementing the systems and processes we have much better oversight, enabling us to respond more effectively and promptly to concerns and improve outcomes for people”. For example, following a review of a person’s incidents of distress the registered manager made a referral to a physiotherapist for an assessment to have a walking frame. This helped improve mobility and significantly reduced distressed behaviours in the community.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Processes were established to ensure people experienced continuity of care when transitioning into the service. Prior to moving in, people were offered regular visits to their new supported living property to help them become familiar with the environment. The management team liaised with key professionals, including social workers, to identify which setting would best meet each person’s individual needs. People were given opportunities to visit at different times of the day and, where possible, attend weekly visits. They were also encouraged to begin moving personal belongings into their property gradually, supporting a smooth and person-centred transition.

Detailed care plans and risk assessments were updated regularly. These plans also included input from external health professionals, such as physiotherapists and occupational therapists, ensuring a comprehensive and coordinated approach to care.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

During the previous inspection we raised concerns with the managers oversight of potential safeguarding concerns. Since then, clear procedures have been embedded to protect people from abuse, neglect, harassment, and breaches of dignity. Staff received comprehensive safeguarding training and demonstrated a strong understanding of their responsibilities. Procedures for identifying, reporting, and escalating safeguarding concerns were firmly established, ensuring timely action and effective communication across the service and with partner organisations. The Registered Manager told us “There is clear processes for recording concerns, conducting investigations, and ensuring statutory notifications are submitted to the local authority and the Care Quality Commission (CQC) in a timely manner”. During our inspection, we saw evidence of this process being followed, including documented safeguarding records, investigation outcomes, and notifications sent within required timescales.

Staff told us they actively monitored for signs of abuse and changes in behaviour. One staff member said, “If I have any concerns about someone I am supporting, I would raise this with the management team. They take the time to come and check the person with me.” Another explained, “I monitor for changes in behaviour, if someone does not appear to be their usual self, I would report it straight away”. Multiple staff confirmed they felt comfortable raising any concerns promptly. These measures meant people were protected, and concerns addressed quickly to ensure prompt actions to keep people safe from harm.

The registered manager had implemented robust systems to ensure individuals deprived of their liberty were fully safeguarded in line with legal requirements. These systems included a comprehensive log of all Community Deprivation of Liberty (DoLS) authorisations, ensuring they remained reflective and up to date. Scheduled reviews were carried out to monitor adherence to statutory requirements and identify any gaps promptly. These measures provided assurance that legal protections were consistently maintained, and individuals’ rights were upheld.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Since the previous inspection the provider had strengthened its approach to supporting people to manage risks by introducing comprehensive risk assessment tools and clear protocols for people to ensure individual risks were assessed, person centred and effectively mitigated.

The provider worked collaboratively with the Local Authority’s Positive Behaviour Support (PBS) team to create detailed behaviour support plans for individuals presenting with distressed behaviours. These plans included proportionate responses to identified risks and focused on understanding the underlying causes of behaviour. They also incorporated proactive strategies aimed at reducing distress to prevent incidents of harm and enhancing quality of life for people. People who required the use of breakaway techniques (a safe physical technique used by trained staff to release themselves from a person’s grip without causing harm) as a last resort when distressed also had tailored cue cards in their rooms. These provided staff with clear, accessible guidance to ensure interventions were used safely, consistently, and only when necessary.

At the previous inspection, people who required support with acute health conditions did not always have these managed safely, however since then risks associated with delegated healthcare tasks were managed. Detailed and up‑to‑date protocols were in place for staff to follow, and these were reviewed to ensure they remained current and reflective of people’s needs. Risk‑mitigation measures were implemented effectively to support safe care and treatment, particularly when staff were providing support with acute health conditions.

Since the last inspection, communication tools had been developed collaboratively with people to ensure their preferences, needs, and choices were clearly understood and consistently acted upon. These tools supported staff to communicate in ways that were meaningful to each person, promoting inclusion, reducing misunderstandings, and helping people to be more actively involved in decisions about their care and daily lives.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We reviewed rotas between November 2025 and December 2025 to assess whether people were able to access the support they needed when they required it. This helped us determine if staffing levels were sufficient and deployed in a way that ensured people received timely and consistent care. We found people received regular support in line with their commissioned hours, ensuring continuity of care and compliance with agreed care plans. People were supported by a small, consistent team of staff, which promoted familiarity and trust. This approach helps people build meaningful relationships with the staff supporting them, ensuring staff teams understood people’s preferences, and respond effectively to their needs. One staff member told us “There are enough staff, and there is always floating staff available to support us. They help check things to make sure everything is completed” and “There has been a dramatic improvement; everyone is working more as a team.”

Staff and records confirmed appropriate training had been completed to ensure people’s needs were managed safely and competently. The provider had also introduced additional training programmes, including breakaway training, which enabled staff to respond proactively and effectively to distressed behaviours. Workshops on understanding and responding to distressed behaviours were also delivered, including guidance on accurate record‑keeping using ABC (Antecedent, Behaviour, Consequence) charts to support effective analysis. This training improved staff confidence in documenting observations and in recognising triggers and outcomes linked to distressed behaviours. One staff member told us, “I found this training really useful.”

Further training had been provided by relevant health care professionals on specific health conditions and on the safe use and management of health‑related equipment.

Since the last inspection, there have been significant improvements in staff supervision. Staff members reported that they had recently received appraisals, which provided opportunities to discuss their performance and development needs. In addition, the registered manager had rolled out knowledge checks in key areas such as Dignity in Care, Breakaway Techniques andPositive Behaviour Support (PBS) to reinforce best practice and ensure staff were confident and competent following training, to meet peoples need safely and respectfully.

We reviewed staff recruitment files and found appropriate checks had been completed in line with safe recruitment practices. This included pre-employment checks such as verified references, interview records, and full employment history. Disclosure and Barring Service (DBS) checks were in place, and risk assessments had been completed where required. These measures ensured that staff employed were suitable to work with vulnerable people and that risks were effectively mitigated.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had established effective systems and processes to assess and manage infection prevention and control risks. An Infection Prevention and Control policy was in place and followed consistently across the service. In communal areas, there was sufficient personal protective equipment (PPE), such as gloves and aprons, to support safe care delivery, and hand‑sanitising stations were fully stocked at the time of our inspection. Staff had completed relevant infection prevention and control training and demonstrated a clear understanding of the measures needed to reduce infection risks. During the inspection, staff were observed using PPE appropriately.

The communal environment was clean, well maintained, and free from unpleasant odours. Waste bins were empty, and hygiene standards were consistently upheld throughout shared spaces.

Relatives did not raise any concerns about staff supporting people to maintain clean and hygienic living spaces, including their own rooms and shared communal areas. These arrangements demonstrated the provider’s commitment to ensuring a safe and hygienic environment in line with regulatory requirements and best practice guidance.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.