Holme House Care Home

“Care was not always delivered in a safe or consistent way, with risks not clearly identified, monitored or acted upon. Care records were frequently inaccurate and contradictory, which meant staff did not always have clear, up-to-date information to guide care. This also affected how responsive the service was, as people’s changing needs and preferences were not always reflected in practice.”

“People’s experiences of care were variable. Whilst some kind and compassionate interactions were observed, dignity was not always maintained and people did not consistently feel listened to, involved or emotionally supported. Opportunities for meaningful engagement and personalised care were limited, particularly for those who remained in their rooms.”

“Staff working relationships and communication were not always effective, and leadership, although knowledgeable, was not consistently visible or embedded in day-to-day practice. This contributed to a culture where staff did not always feel confident to speak up or assured that concerns would be acted upon.”

“Whilst there were some positive examples, including improved healthcare access and inclusive practices, these were not consistently experienced across the service. Overall, the service was not yet delivering consistently safe, effective, caring, responsive or well-led care.”

“We raised all identified concerns with the provider and also made safeguarding referrals to the local authority safeguarding team where necessary. The provider has been responsive to the assessment findings and has started to implement improvements.”

“The provider was in breach of 3 legal regulations in relation to need for consent, safeguarding and good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.  ”