Holmwood Gardens Domiciliary Care Services

Date of inspection 7 July 2025 to 25 July 2025. The inspection was prompted due to concerns received about safe care and treatment and a lack of effective management oversight. Concerns related to poor staff practice, medication management and safeguarding concerns. Holmwood Gardens provides personal care for people living in their own tenancies. The service provides support to autistic people and to people with learning disabilities. At the time of our inspection there were 18 people receiving a regulated activity under the registered location. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. People had progression plans in place to develop new skills and experiences which staff supported people to achieve. Relationships which were important to people were developed by staff teams to maintain important connections with family and friends. We identified under the key questions Safe and Well Led the service was in breach of legal regulations in relation to safe care and treatment, safe and effective staffing and good governance. Risk management in relation to how individual’s emotional and behavioural needs were assessed, planned for and mitigated were not sufficiently robust and at times meant people were not safe from potential and actual harm. People with acute health conditions did not have their health needs managed safely. Staff were not always deployed to meet people’s needs. They also lacked training, skills and knowledge to support people effectively to manage distressed behaviours and specific health care tasks. Incidents were not managed or reported in line with the provider’s policy. Leaders of the service did not have effective oversight, knowledge and understanding of people’s behavioural and emotional needs and the management of incidents was poor and did not lead to a culture of learning and improvement. The provider was previously in breach of legal regulation in relation to good governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation. ​ We have asked the provider for an action plan in response to the concerns found at this assessment.

Holmwood Gardens was rated Requires Improvement overall following its August 2022 inspection, with a breach of Regulation 17 (Good Governance) identified due to ineffective quality monitoring systems, unrobust recruitment checks, inconsistent medicines management, and gaps in staff training oversight. Strengths were noted in person-centred caring and responsive practices, with staff demonstrating genuine knowledge of and commitment to the people they supported.

Holmwood Gardens Domiciliary Care Services was rated Good overall, with safe, effective, caring and responsive domains all rated Good, supported by strong person-centred care, robust safeguarding and effective medicines management. The Well-led domain was rated Requires Improvement due to inconsistent staff supervision frequency, absence of annual appraisals, incomplete audits, and lack of formalised recorded meetings between the registered provider and registered manager.