Archived: Holly 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

We reviewed 7 quality statements for this key question in relation to how well the service was managed. Staff and visiting professionals spoke highly of the management team. Staff felt valued and supported. We found improvements had been made to record keeping. However, we also found there was some lack of managerial oversight in relation to documentation. The management team acted on this immediately following feedback.

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 the culture at the service was “open” and “honest.” Other staff comments included, “I think it's lovely here, like a family. The best place I've worked. It's a positive work culture, everyone helps everyone. All staff are kind and caring and put people first” and, “People do speak up when something goes wrong and we learn from it.” There was a focus on improving clinical standards at the service. One staff member said, “We have trained all the nurses now to be competent to take bloods and insert catheters. It's made a huge difference not having to ask community teams to do it because we know people and can judge when to try and take someone’s blood for example.” Management told us the provider had an agreed vision for their future strategic development in place.

The management team had oversight of the service via audits and walk round observations. The registered manager told us they were supported by the clinical operations manager. We reviewed audits and digital records of the provider’s processes and found the majority of these were fully compliant or actions were in place with timescales to monitor.

Staff spoke highly of the management team. Comments included, “They are very approachable and always there to help. [registered manager] will always show up in a crisis. I know I can call her any time and she will come and help” and, “They [registered manager and deputy manager] are both very approachable and give good advice. They do help out if we're short staffed.” The management team spoke kindly about the people they supported. They knew how people were and spoke to them daily.

The management team had systems to support staff, these included flexible working and an ‘open door’ policy.

Staff knew how to raise concerns about poor care. Comments included, “I would be the first person to flag any concerns. If I see anything that worries me, I would follow the procedure, keep going higher, and then I would whistle blow” and, “I would definitely raise concerns. I would report it to my team leader and then I would report to the nurse. I would go to [registered manager] if it wasn’t sorted and I know she would sort it.”

There was a complaints process in place. No complaints had been received in the past twelve months. The whistleblowing policy and procedure was re-visited with staff during their one-to-one supervision.

Staff told us the staff team was very diverse in terms of culture and experience. Overseas staff had been supported to settle into the community. The management team told us religious and cultural needs of staff were met at work. They told us staff had embraced the multi-cultural new staff team.

The provider had the required personnel records including safe recruitment and sponsorship recruitment procedures in place. There was an equality and diversity inclusion policy with accompanying training for staff.

Staff told us the management team regularly reviewed and monitored their work and records. Management confirmed they had regular monitoring and auditing exercises, which included spot checks, a dip sample of records and observations of staff support.

There was some lack of managerial oversight. For example, the concerns we noted around care planning, documentation and mental capacity assessments had been noted during audits, but no follow-up checks had been carried out to monitor if improvements had been made. However, these areas had been addressed by the clinical operations manager following our feedback. They gave assurances to on-going regular monitoring and oversight.

Relatives told us their family members were going out into the local community far more since the pandemic. They were attending social events and had good relationships with the local residential community.

Staff and leaders told us they worked closely with professionals who visit the service. They collaborated and took guidance to provide appropriate support to the people at Holly Lodge. Staff and leaders told us they had good working relationships with all visiting professionals.

The professionals we spoke with were complimentary about working alongside the staff at Holly Lodge. Comments included, “Whenever a site visit has been made, the information is always clear and up to date”, “They responded to medical emergencies appropriately and with kindness”, [They have a] “Proactive, creative thinking and positive working relationship.”

We saw evidence of medical and social care professional guidance in people’s care records and how this had been incorporated into their care plans.

One staff member said, “I get lots of training. I’ve not long had my appraisal and my revalidation is due soon. I've been working with a newly qualified practitioner to develop their practice too.” Another staff member said, “I do feel trained to do my job. If I wasn’t sure, I would ask. Staff told us learning was shared amongst the team. This was done in handover, meetings or via messages in the hand-held devices.

The management team had a training matrix to monitor staff training which was due, completed or overdue. Staff would be sent regular reminders to complete their training and there was a dedicated room for them to complete on-line training in the building. Staff training was up to date. Management told us learning was shared within the organisation.