Holly Lodge Residential Home

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

There were management systems in place to ensure the quality of the service was checked and monitored. The registered manager submitted notifications to CQC as required.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager encouraged staff to speak up. They told us, “I talk to the team about being positive, if you can't talk to me, try (the deputy manager or provider) but just say things, don't bottle it up”. Staff told us they were listened to. Staff said, “If we ask for anything for residents we get it i.e. pressure mats”. And, “They would let me have time off if I needed it for family or health.”

At the last inspection we identified a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to effectively assess, monitor and improve the quality and safety of the service provided. Accidents and incidents had not always been reviewed by the management to reduce the risk of re-occurrence. Quality assurance systems, such as audits, had not always led to care plans and risk assessments being up to date. At this assessment enough improvement had been made and the provider was no longer in breach of regulation 17. There were systems in place to ensure the quality of the service was checked. For example, medicines were regularly audited. Audits ensured that guidance for staff was in place, for example, care plans were up to date. Incidents and accidents were audited and reviewed by management to ensure that lessons were learnt, and actions had been taken. Notifications were submitted to CQC as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.