Elliscombe House

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

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At the last assessment this key question was rated good. At this assessment this rating has changed to requires improvement. This meant there were significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

This service scored 39 (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 did not always have a clear shared vision, strategy or culture that promoted transparency, inclusion or respect and this negatively affected people, staff and the stability of the service. Staff, relatives and people described significant disruption caused by the conduct of the owner, which impaired the service’s ability to embed a positive, values‑based culture.

Staff and relatives consistently reported behaviour from the owner they felt was insensitive, inappropriate or dismissive. One relative said the owner was, “Arrogant. He thinks he’s charming, but he is far from charming. He has no idea how to speak to people. He has no clinical background at all. He doesn't understand people's needs.” They also described how he had upset their family member through careless personal remarks. Another relative described how the owner had entered their family member’s room without being invited and was demeaning towards them. They told us, “This was very upsetting and humiliating for us. He never even apologised this is just one example of his insensitive behaviour. He is disruptive everyone is on edge when he's in here. He [the owner] shouldn't be anywhere near the place. His behaviour is inappropriate.”

Staff said the owner’s presence created tension and anxiety, and morale was directly affected. People told us they felt well cared for by staff, but several described distress or uncertainty caused by decisions made by the owner, including being given notice to leave the home at short notice. This meant people would need to find another care home to move to. People did not understand why this had happened, and did not feel consulted about such an important decision.

Although the registered manager, deputy manager and heads of departments were respected and promoted a kinder culture, their efforts were undermined by the owner. This meant the culture varied depending on who was present in the home or how much pressure was being exerted by the owner. This prevented the service from consistently displaying the values expected in a professional, effective, and well‑led care service.

Leadership within the service was mixed. Staff told us they felt valued and listened to by all members of the on-site management team. The registered manager and deputy manager were described as capable, compassionate and supportive. People and relatives gave numerous examples of their responsive, person‑centred leadership. One relative told us, “[The registered manager] had made huge changes; there was total transparency. I couldn’t praise the staff enough.”

However, the provider’s overall leadership was not effective. The owner’s conduct had a detrimental impact on multiple aspects of leadership, including staff morale, the emotional wellbeing of people and trust in the organisation. We were told, “As a management team, we are completely deflated, unable to work and run the home the way we want to and now working in constant fear [due to the owner’s behaviour].”

Staff described the owner as, “Not approachable or supportive” and “He does not understand care homes in the slightest. He has no priority for care. He does not understand what we do or how long things take.” Staff said the owner created a disruptive, tense atmosphere. Key members of the home’s management team were seeking alternative employment due to the pressures arising from the owner’s conduct.

Several people and relatives told us the owner’s behaviour was inappropriate and intrusive. Staff and relatives described occasions where he entered rooms without knocking or made inappropriate comments both to people and staff. Two staff members described a recent incident when the owner had entered a person’s bedroom without knocking or gaining consent whilst the person was receiving an intimate nursing care procedure. One staff member said, “This was disgusting behaviour.” This contrasted significantly with the inclusive, compassionate leadership demonstrated by the on‑site management team.

The inconsistent approach between the on‑site management team and the owner meant the service could not rely on stable, consistent and unified leadership. While day‑to‑day management was effective, the owner’s behaviour and influence adversely affected the respectful, person‑centred culture needed to ensure sustained improvement.

People and staff did not feel consistently safe to speak up. Staff repeatedly told us they were worried about raising issues related to the owner, describing him as intimidating or dismissive. One member of staff said, “He upsets people really badly. We never get any praise, it’s just criticism.”

Some staff felt that raising concerns could lead to repercussions or simply would not result in any meaningful change. One staff member told us, “[The owner told me] I was not to communicate with you [an inspector] or CQC. He [the owner] made it clear that my job is not safe if I speak to CQC.” Certain staff expressed fears about their job security, and one told us, “If I could leave, I would but I cannot.” This created an environment where concerns could be suppressed rather than openly discussed.

People living at the service also experienced decisions being made without consultation or clear explanation. People had received sudden notices requiring them to leave the home, and people told us this created fear and uncertainty. One person described receiving a letter telling them to leave by a specific date and said they were, “Very anxious. I have been happy for the time that I’ve been here although I am feeling very anxious now” because they did not know what was happening or why they had been asked to leave.

Although people and staff trusted the on-site management team, the presence and behaviour of the owner acted as a deterrent to open communication. Therefore, the organisation was unable to demonstrate that it promoted or protected people’s ability to speak up without fear.

The provider did not demonstrate an inclusive approach to equality, diversity or fairness in the workforce. Care staff consistently reported a lack of value, appreciation or recognition from the owner, and several described feeling dismissed, belittled or undermined. One staff member said, “We never get any thanks, never appreciated by him.”

Some staff felt financially and contractually vulnerable. One described feeling unable to leave despite being unhappy, saying, “He [the owner] can be very difficult. I worry at times. Being on [a specific employment contract], I don’t have much choice. I would have to stay, I couldn't leave. If I could, I would leave.”

Relatives and staff described occasions where the owner’s behaviour was insensitive or discriminatory. Staff told us the owner had made comments about personal matters without any regard for people’s feelings or needs, creating an environment where people felt singled out rather than supported.

While the on-site management team worked hard to support staff member’s physical and mental wellbeing and made reasonable adjustments for staff when they were needed, these positive practices were not matched by the owner. Comments from staff included: “I'm so depressed about working here I'm actively looking for other jobs; my reason [is the owner]. I've been in tears myself because of [the owner’s] constant bullying and harassment”, “He is constantly on at us. He has no filter and no empathy with anybody. I just simply can't go on like this. I am actively looking for another job”, and “I feel drained mentally. I do not trust [the owner now]. I know that I'm not working to the best of my ability. I'm actively looking for another job. I cannot work here under these conditions.” This meant staff did not experience a fair, inclusive or respectful working environment.
 

Governance arrangements were not always effective and did not ensure that risks, responsibilities and accountability were managed safely or consistently. Evidence showed that key systems were undermined by the owner, including unpaid invoices affecting essential safety equipment.

The lift remained unrepaired for several hours recently because previous bills had not been paid, leaving people unable to return to their rooms. One staff member said, “In my view, elderly residents’ wellbeing has been put at risk. We had a lot of residents stuck downstairs all afternoon where usually they want to go back up to their rooms and some people needed or wanted to go back to bed.” There had also been a long delay in replacing a fire curtain for the same reason. One staff member told us, “The fire curtain downstairs has finally been fixed. I reported this as faulty in October 2025 and it has only been fixed earlier in March [2026], so effectively the fire curtain was out of action for five months.”

Decision‑making processes were inconsistent and not always transparent or person‑centred. Governance arrangements and reporting, which had previously worked well, had been changed by the owner to a format they were happy with. We were told, “Governance has slipped as we simply don't understand [the owner’s] spreadsheets. We have no ownership of oversight anymore and don't understand the governance or where there are gaps or improvements needed. Once again [the owner] is making these decisions without any experience of care or nursing care.”

Despite these serious concerns, the on-site management team were managing the home as best they could and were trusted by staff and people. Staff described good communication, accessible care plans, regular supervision and improved coordination. This demonstrated strengths in the on-site management team. However, this was not enough to compensate for the disruption and confusion caused by the owner. Governance structures were therefore not robust or sustainable, as the owner’s actions repeatedly destabilised the service.

The service had some positive relationships with community partners, such as local GPs and visiting professionals. However, some relationships were undermined by the owner and strained key partnerships. Safety issues arising from unpaid invoices affected the reliability of external contractors such as the lift company, and delays in essential repairs placed strain on both operations and relationships.

Feedback from health and social care professionals was sought as part of our assessment. One social care professional described their organisation have a “difficult relationship” with the owner at times who they described as “unprofessional at times.” One health care professional told us they were currently in the process of undertaking several reviews and assessments of people living at the home to ensure these were up to date in view of the concerns raised.

People told us they were able to access healthcare services regularly, and relatives described good communication between the staff and clinical teams. One person described how a GP attended promptly and how this supported end‑of‑life planning.

There were community‑focused activities, including promoting and displaying people’s own artwork, some of which was on sale with funds going to a local hospice. The head chef was leading a baking session on the day we visited which people enjoyed. Food cooked at these sessions was shared with people, relatives and other visitors. There were various gardening projects led by the head gardener which people took part in. These helped people stay connected and contributed positively to their wellbeing.

Partnership working and people’s involvement in the local community was supported by the on‑site management team. However, the absence of a stable and professional provider‑level leadership approach meant the service could not fully embed or sustain effective partnership working.

The provider did not demonstrate a culture of continuous learning, improvement or innovation. It was evident the owner had not learnt from previous concerns or feedback, including from the last inspection.

Following our last inspection in July 2025, numerous concerns were raised with us about the conduct of the owner and the detrimental effect this was having on people, relatives, staff, and the service overall. We met with the owner and discussed this issue during the last inspection. They accepted our feedback and agreed, “To withdraw from the hands-on approach.” They agreed to visit the home a maximum of once a month and “Only to have contact with [the registered manager]”. They confirmed this agreement in writing to us on 21 July 2025.

It was evident this agreement had been breached by the owner. We were told by staff, “In regard to what you agreed with him [the owner] back in July [2025], he's either forgotten or just chosen to ignore it.” Therefore, the same themes of inappropriate conduct, poor communication, lack of consultation and the detrimental effect on the service had continued.

Although the on-site management team encouraged reviews, reflection and learning, including responding to accidents, incidents and updating care plans, this was not embedded across the wider organisation. Staff told us they felt unsupported by the owner and believed their efforts were often undermined by them.

The lack of organisational learning created a cycle where issues continued or worsened rather than improving. The owner had failed to demonstrate that they had an effective approach to partnership working or sustainable improvement. One staff member said, “He doesn't take responsibility for all the issues he creates here.” Another staff member told us, “He has no background in care or with care homes and certainly nothing to do with nursing care, so he has nothing to add here. He should just leave the home alone."