Holm Lodge

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 the last inspection the provider had failed to provide consistent information in care plans and risk assessments, there had been no analysis of falls data and auditing processes had failed to identify some concerns within the kitchen. The feedback process from people contained no detail other than a ticked box. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection improvements had been made and the provider was no longer in breach of regulation 17. Everyone spoke highly of the registered manager who was approachable and a visible presence throughout the service. Staff, people and their loved ones told us they had regular opportunities to raise any issues or concerns and they were confident that appropriate action would be taken. The registered manager had a clear vision about maintaining and improving the service and providing the best care and support to people. Effective auditing and feedback processes were in place and the registered manager was aware of their responsibilities under the duty of candour, to report certain events to the local authority and CQC. Logs were kept of learning from events and incidents and this was shared with staff.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they were confident the registered manager was leading the service well and had the best interests of people at the centre of the actions they took. The registered manager had a clear vision for the future of the service concentrating on providing the best service to people whilst managing the welfare of staff. Staff told us they were able to contribute through team meetings, one to one meetings and handover meetings, to the running and development of the service. A staff member said, “Can raise issues with managers and we have team meetings regularly. They do listen.”

Minutes from staff team meetings recorded active involvement of staff. Views and opinions were valued by the registered manager to help drive improvements within the service. The registered manager was open and honest about recent events at the service which had resulted in several staff leaving. They had kept the remaining staff fully up to date with the changes and actively involved them in shaping the future of the service.

Staff told us that the registered manager and wider management team were approachable and supportive. Comments from staff included, “(registered manager) is very good and is getting things done,” “Manager is approachable and supportive. (New deputy manager) is very helpful and walks the floor, does not just sit in office” and “Manager is approachable, supportive. Can bring any concerns.”

The service was relatively small and this was reflected in the number of staff employed. The staff team were supported by supervisors and managers. Regular team meetings and supervision meetings on a formal level took place but there were also daily opportunities to speak with managers if needed. Wellbeing and equality and diversity policies were in place. The registered manager supported staff, enabling them to provide the best possible support and care for people

Staff were actively encouraged to speak up and contribute ideas, raise concerns and be involved in the development of the service. Staff told us of regular team meetings, hand over meetings and daily conversations with the registered manager. Staff were confident to use the whistleblowing process if needed.

In addition to staff, there were meetings held for people and relatives. Minutes from residents meetings showed similar opportunities for people to raise issues or concerns and to suggest improvements and contribute ideas. Meetings with relatives were held one to one and were recorded. Relatives told us that communication between themselves and the service was positive. They were always able to raise any concerns and also were kept informed of any issues affecting their loved ones or wider issues affecting the service.

The staff at the service represented multi-cultural heritage and they supported people with diverse and different backgrounds and faiths. Staff and people told us that the service was ‘homely’ with everyone getting on well with each other. A staff member said, “We are one team, we are all different and we all look after each other.”

Care plans contained a section describing people’s backgrounds and any cultural or religious needs that they might have. Different religious faiths were represented and these were recorded and respected by staff. Local religious leaders sometimes visited the service. Staff had completed equality and diversity training and supported people appropriately to their individual needs.

The registered manager told us that care plans were being updated regularly and that the service would soon be moving to an electronic system of recording people’s details and daily notes. Audits of all key areas were in place, overseen by the registered manager. The registered manager demonstrated their overview of the service and importance of the ‘general management audit.’ Staff had clear responsibilities and roles which contributed to the registered manager maintaining clear oversight of daily tasks.

At the last inspection there was a regulation 17 breach relating to conflicting evidence found in risk assessments and failures in the auditing processes to identify trends with accidents and incidents. Risk assessments had improved and were specific to people which had resulted in better support for people and minimising the chance of recurring risks for example, falls. Auditing processes were now robust. The general management audit was carried out 3 monthly and every aspect within the audit process was scored to enable a direct comparison with the previous audit scores. This then showed areas of improvement, areas that had stayed the same and some areas where improvement were needed. Monthly auditing processes were in place for all areas including, medicines, kitchen safety, laundry, environment and care plans and risk assessments.

People and their loved ones told us that they were supported by other health and social care professionals and that any religious or cultural needs were met. Some people chose to go out into the community visiting local shops and restaurants with the support of their relatives. People told us that the service was homely and set in a semi-rural location which made them feel part of the local community.

The registered manager and all staff report positive working relationships with statutory health and social care partners and professionals. Staff told us that some people regularly went out of the service into the community, some independently and others with the support of loved ones.

The feedback from professionals with links to the service was similarly positive. Professionals reported good communication between the registered manager and staff which enabled visits to run smoothly with support when on site. Professionals told us that people always were happy in the company of staff and were supported to be as independent as safely possible. A professional summed up their experience of working with the service, “Very effective working with the staff and good communication. They were aware when I had planned to visit in advance so communication appeared effective between the care home team. The staff followed guidance provided by rehab staff regarding positioning and use of equipment. The patient always appeared happy and knew some of the staff’s names.”

Care plans contained details of other people and professionals involved in their care and support. At a glance staff were able to see the list of contacts and set up appointments as needed. Everyone had a hospital passport which contained a summary of key health and social care information about people, available to other professionals if needed in an emergency or a transfer between services situation.

The registered manager told us about a regular multi-agency meeting held at the service to discuss people and their needs. Several key professionals were involved in these meetings which were designed to ensure people’s best interests were considered with their care. Decisions and any changes or improvements to care provision were recorded and details shared with all staff.

The overview maintained by the registered manager of auditing and quality assurance meant that they had a clear view of how the service was doing and any learning that would be helpful to share. Monthly lessons learned documents were produced for all staff. The registered manager kept up to date with developments on health and social care with regular contact with the local authority and the CQC. The registered manager was signposted to the county wide registered managers forum where managers got to together to share good practice and ideas.