Holmwood Care Centre

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

Safe - this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question requires improvement. At this assessment we assessed a total of 8 quality statements from this key question the rating has changed to good. This meant people were safe and protected from avoidable harm.

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 systems in place to identify concerns. Incidents and concerns were investigated. The manager shared lessons learnt to their staff group and implemented these promptly within the home to embed good practice and reduce the risk of them from happening again.

People had reviews with external health and social care professionals to ensure their overall healthcare needs were being met.

Permanent staff understood people’s individual risks and had good knowledge and understanding of this. However, details within people’s care records required strengthening to ensure that this was consistent with people’s planned care.

The provider’s policies and processes for safety were aligned with other external agencies who were involved in people’s care journey to enable shared learning and drive improvement.

People told us they felt safe by the staff who supported them. One person told us, “Don’t feel unsafe, if something big, I would go to the manager or people I know”. All relatives we spoke with also felt their family member was kept safe.

Staff received training on how to recognise and report abuse and knew the processes to follow to keep people safe. All staff felt confident to raise concerns with the management team and any issues raised would be fully investigated to make sure people were protected. The provider understood their responsibilities regarding the action to take to protect people from harm, we saw examples where action had been taken to protect people where required.

Health and social care professionals confirmed that where safeguarding concerns had been raised, prompt action had been taken to safeguard people and notify relevant agencies, and where appropriate the person’s relative.

The provider’s safeguarding policy gave clear guidance for staff about how to raise a safeguarding alert. Any safeguarding concerns were recorded appropriately and reviewed to ensure the relevant professionals were notified. Where the provider had deemed people were being deprived of their liberty, applications had been sent to the local authority for authorisation. They kept track of application processes, to ensure key dates were met. The provider met their legal requirement to notify the CQC where a person had been legally deprived of their liberty.

People’s care plans and risk assessments required improvements. Details held within the records we looked at were not always comprehensive or accurate in how to keep people consistently safe. For example, a wound care plan did not describe the correct prescribed dressings, while another person’s care plan for smoking was not updated following a review and change in their care. However, staff had good consistent knowledge of people’s care needs and how to mitigate risk of harm.

The provider confirmed they were aware that information held within records required improving, and there were imminent plans to change to a different electronic care planning system. The new incoming provider had used this electronic system in their other services and found records were more up to date and accurate, while allowing staff to enter the required information in a timely way.

People and where appropriate, their relatives, were involved in managing their individual risks to ensure they remained safe. Relatives felt staff knew how to keep their family member safe, and were involved in their family member’s care, with any changes or incidents also being communicated.

Staff recognised risks to people and were consistent in their knowledge as to how they supported people to mitigate risk in the least restrictive way.

People were supported to do the things they wanted to do, and staff helped them to do this safely. We saw staff supporting people safely around the home and in activities. Staff were patient and supported people at their own pace.

People did not express any concern in relation to the safety of the environment. Relatives also felt the environment of the home was safe. People had access to a secure garden areas and a choice of communal areas to sit in throughout the day. Key coded access meant people were secure in the home in line with their best interests.

Staff were clear what their responsibilities were in relation to the upkeep of the home.

The environment of the home appeared safe and well maintained.

Maintenance was well managed and there was clear information to demonstrate services and system checks were completed.

All staff we spoke with felt their training needed enhancing. One staff member told us they would benefit from more practical training rather than electronic learning. The manager and new incoming provider confirmed that more training specific to what staff needed had been scheduled for staff. Staff told us they had not had many supervisions or spot checks of their competency. This was an area also identified by the provider as an area to improve upon.

All people felt improvements were needed with the skills and experience of some agency staff, however felt staff and other agency staff had the right skills and experience to support them with their care needs.

Most people raised concerns about low staffing levels, however we did not find this impacted on people’s safety but did have an impact on how people’s dignity needs were met. We have reported on this aspect under caring.

People told us staff responded quickly to call bells to check their safety. Relatives also felt staff responded quickly for safety.

Staff felt people were safe with the number of staff on shift, and did not feel people’s safety was compromised. The manager told us there had been a sudden loss of some core staff so they were actively recruiting into the vacancies. They confirmed that while agency staff were booked in advance, further work would be done to block book agency staff, to promote consistency for people.

The provider followed safe recruitment procedures before staff began working in the home.

All people we spoke with told us the home was always clean and tidy. One person said, “Always clean, very nice place”

People were protected from the risk of infection as staff were following safe infection prevention and control practice. Staff had access to personal protective equipment (PPE). Cleaning staff told us they had enough cleaning equipment to support them to carry out their roles effectively.

The home appeared clean and clutter free.

Regular audits were undertaken to ensure the areas of the home were maintained to a good standard.

All people we spoke with had no concerns around the management of their medicines and felt this was well managed. People also felt supported with management of pain.

Nurses and senior care staff had received training in medicine administration, and their competencies were regularly checked. Staff told us they had sufficient time to administer medicine, and the medicines were well organised with sufficient stock.

Medicine record keeping was clear and accurate. Staff followed safe practice when administering medicine to people.



The process of receiving, storing, and returning medicines was good. There were medicine audits in place, which included spot checks of staff’s practice, record keeping and medicine counts.