Holly Tree Lodge Residential Home Derby

The assessment was carried out due to the length of time since the last assessment.

The provider’s systems and oversight arrangements were not always effective in ensuring people received safe, well-planned and responsive care. Risks were not always fully assessed, and care records did not always contain accurate or up-to-date information to guide staff. Although staff often understood people’s needs well in practice, this knowledge was not always reflected in care plans or risk assessments.

There were not always enough staff deployed effectively to meet people’s needs, particularly during busy periods. This affected staff capacity to provide meaningful engagement and respond to people’s immediate needs. Governance systems did not always identify concerns relating to staffing, medicines management, environmental risks or documentation.

The provider worked positively with healthcare professionals and staff sought advice when people’s needs changed. However, this information was not always reflected in people’s care records, which increased the risk of inconsistent care delivery. Systems to monitor care quality and support improvements were not always effective.

Staff promoted people’s independence and wellbeing and made efforts to celebrate important occasions and provide personalised support. However, opportunities for meaningful activities and future care planning were limited.

People received care from a staff team who knew them well and were committed to providing kind and person-centred support. Throughout the assessment, people, relatives and professionals spoke positively about the caring approach of staff and the relationship built within the home. Staff understood people’s preferences, routines and communication needs and treated people with dignity and respect.

During the assessment, the provider responded positively to feedback and took some immediate action to address concerns identified. The provider acknowledged improvements were needed and shared plans to strengthen oversight. It will take further time for them to embed this and to be able to demonstrate its effectiveness.

At this assessment, we found 1 breach of regulation in relation to good governance.