Holly Cottage

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

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 provider was in breach of legal regulation in relation to the governance of the service.

We found several issues which meant we could not be assured that people were always receiving safe and effective care. Care plans sometimes lacked detailed information and there were gaps in recording. Accidents and incidents were not always reported, and the provider had no system in place to capture accidents, incidents and other significant events within the location, or learn from them. New systems had been put in place which exposed people to increased risk from the environment. A business continuity plan was in place but it lacked sufficient detail to ensure it would be effective.

There was a leadership structure in place, with the service manager supported by the operations director and a team leader. Staff told us that they had regular supervisions and monthly team meetings. We saw evidence of house meetings. External professionals and relatives told us that there were always prompt responses from the management team, and a good working relationship. Relatives told us that the manager was approachable, knowledgeable and compassionate.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found a mixed picture regarding the service’s culture and future direction. Although the provider told us there was a shared vision, strategy and culture we found this was not well evidenced or fully embedded. The culture was closed in some areas and some practices, including recruitment practices, were not fully inclusive. The manager was an experienced care manager and told us they were dedicated to staff development and the wellbeing of their staff.

People we spoke with told us that communication with the home was always open and honest. A relative told us that the management and staff all shared the same ethos and worked seamlessly with external health professionals to ensure the best outcomes for people.

The management team was present during both visits to the location, and we observed good interaction with staff and people. Staff told us they had no reservation in approaching the manager for advice, and where issues arose, the manager was hands on, supporting the staff through it.

The manager understood the context in which they delivered care, treatment and support. They were open and honest. Leaders had skills, knowledge, and experience. However, they had not independently identified the concerns we found during our assessment. We received positive feedback from family members. One told us, “[The managers] have a gift for compassion, care and knowledge in combination”. This sentiment was reflected by the other relatives we spoke with. Staff told us that the managers were fair and went above and beyond to support them. The provider had recently appointed a team leader, thus broadening the management structure. This meant some of the responsibilities that were normally carried out by the manager and operations director, could be delegated to the team leader.

The provider aimed to foster a positive culture where people felt they could speak up and their voice would be heard. The provider had recently carried out a people, families and external professionals survey, which gave everyone the opportunity to give their views on the care people received. However, one person had exercised their right to speak up but their concerns had not been fully addressed and it was not clear if any reflection or learning had taken place.

We saw the complaints policy of the provider and there were posters within the location that told people how to raise issues and how to complain. This had the numbers for the local authority as well as the Care Quality Commission

One external professional noted on their feedback that the service had, 'A very centred approach to supporting residents. Holly Cottage is a family, and this is integral to positive outcomes.'

The provider did not always value diversity in their workforce. The provider had recruited the majority of staff from overseas and told us they had done this to ensure a consistent staff team. Whilst this worked well, we questioned the legality of excluding certain staff from being considered for employment. As a result of this, we were not assured that the Provider’s recruitment process was always fair and inclusive and we found this approach went against the provider’s equality, diversity and inclusion policy.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not always operate effective systems to monitor and improve the quality of the service or to mitigate risks. Records were not always accurately completed and this placed people at risk of poor care and treatment. Following our onsite assessment the provider told us they were putting short care summary records in place for each person. The provider’s systems for recording and learning from accidents and incidents were not always operated effectively. This meant they missed opportunities to improve the care and treatment for people. The business continuity plan for the location was incomplete and had not considered several critical risks which were highlighted to the provider.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The manager worked well with other professionals, and this cascaded down to the staff team. Staff were empowered to contact health professionals where issues arose without waiting for the manager.

The people were integrated within their village community. People went out for walks and attended coffee mornings and pub nights at the village hall. A family member told us that staff encourage their relative to go out, even though they are often hesitant to do so: 'He went to the village hall again recently and was very proud of himself.' However, we did not see robust evidence of engagement with the wider community.

Incidents had not always led to clear reflection and learning. The provider told us they were keen to improve the service but had not independently identified the issues we found during this assessment. The management team were keen to look for innovative ways to improve the environment, but this process had also introduced additional risk.

Staff training was up to date, and the provider told us they were always on the look out for any additional training that would improve the knowledge of the staff team. They were receptive to the concerns we raised and told us action was already planned to address some of them.