Elmwood Residential Home Limited

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

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

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained Requires Improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 61 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. During this assessment, we identified shortfalls in the safety of the service and the support people received. The provider had not ensured effective systems were implemented to monitor the experience of people living at the home. This had led to some elements of the culture of the service being task-based, rather than focused on people’s personalised care needs.

The management team had a plan to improve the service and told us the issues found during this assessment would be added to the plan, if not already actioned.

The provider had recently employed a new manager who understood the context in which they delivered care, treatment and support, and embodied the culture and values of their workforce and organisation. The manager had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Some staff said they felt the new manager was very open and approachable, and promoted equality throughout the team. Staff said the manager had helped them to work better with systems and processes and was good at communicating with the team. Some staff also said the manager was responsible and had taken actions to help all carers feel equally treated. They said the manager and deputy manager would always try and understand any problems and help solve them and were very supportive to staff.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt confident that any concerns raised with the manager would be taken seriously, fostering a culture of openness and trust. Where necessary, concerns would be treated confidentially. The service had a complaints policy in place, which listed the process of how complaints could be made, and what they should expect. The policy also listed a range of services staff could complain to outside of the service if they felt the need to do this. People and their relatives told us they were able to contact the registered manager to raise concerns if required.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they felt supported by the management team at the service. Staff reported that as a staff team, people worked together well and supported each other. One staff member told us, “The new manager is approachable and is amazing, she has started to put us through the new training, if it was not for her and another leader, I am not sure the care team would be as good.

The provider was in breach of the legal regulation relating to good governance. The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes. There were several quality assurance systems in place, but these had not always been effective in identifying the areas for improvement found at this assessment.For example, “cleaning rotas” to record cleaning had taken place were missing multiple entries and were not dated. Records relating to people’s care and treatment were not always complete and up to date. For example, one person’s care plan was missing advance care planning. This means they might not have had the time, information, or support to make decisions about their future.

There were insufficient systems and processes to monitor the regular servicing of fire safety equipment. As a result, necessary actions to improve the quality and safety of the service were not taken. Fire safety measures remained insufficient—for example, an outdated fire extinguisher was still in use, evacuation drills had not been carried out for new staff, and an evacuation chair had not been serviced since August 2023.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider was working collaboratively with the local authority and other system partners to help drive improvements within the home. Regular multidisciplinary meetings had taken place, where progress with planned actions had been reviewed.

We spoke with representatives from the local authority who told us they were happy with the level of engagement from the provider, who were committed to making the necessary improvements. One staff member told us, “We have good relationships with district nurses and the GPs come in in on Tuesdays and Fridays. We have quite good communication with them, and they appreciate those things, so it is good”.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The existing systems had not effectively identified key issues or driven service improvements, leading to missed opportunities for learning and development. While initial steps had been taken—such as updating care plans and introducing more meaningful activities—several areas still required attention.

Encouragingly, the manager and staff demonstrated a strong commitment to making positive changes. Staff highlighted the rollout of a new data recording system and improved collaboration between care and kitchen teams, supported by enhanced communication.

The manager used their expertise to develop staff skills and improve the quality of service.

Improvement efforts were reinforced through partnerships with local authority teams, and the recent involvement of an external quality assurance consultant added further capacity to drive sustained progress.