Elton Park Care Home

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 our last inspection we rated this key question requires improvement. This key question has improved to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Monthly staff meetings were held where staff discussed any changes in the service and people’s wellbeing, lessons learned and updates on the requirements of their role. The minutes showed staff were asked for their views and were empowered to contribute to the meetings. Actions were recorded which showed comments were valued and listened to.

A staff member told us how the staff were working together to improve as a team, identifying how strengths and weaknesses could be identified and improvements put in place. They were enthusiastic and committed to the service and providing good quality care and felt if the service continued as they were improving, “We can thrive and be a top care home.”

A member of the senior team told us about the procedures for the morning shift, which included meeting with the staff team first thing, allocating and discussing the requirement for the shift, following the medicine round the senior checked the work undertaken and actions taken to ensure people had received the care they required. If any issues arose a solution would be found.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Since our last inspection, there had been changes in the management of the service, the last registered manager was deregistered in August 2024, the current manager has been in post since August 2024. They were in the process of submitting their registered manager application. They were supported by a deputy manager. The provider told us the deputy manager worked one day a week in another of the provider’s services. This enabled sharing of good practice and learning between the services.

To free up the management team, the provider had implemented a centralised administration and a team for payroll.

The provider told us they had made a decision not to take new people into the service following the departure of the last manager, this enabled the new manager to settle in and improvements to be made, including in care plans and staff morale. The provider was now accepting people into the service. The provider told us they visited the service weekly and was able to monitor the improvements being made.

A staff member said, “There have been big changes since the manager started, all for the better and though improvements were being made there was still room for continuous improvement.” A social care professional told us, “[The service] had a period of instability but [manager] is an experienced manager and has worked hard to put in place all that was required.”

People and relatives knew who the manager was and said they were approachable. A person told us, “Manager is very pleasant…[manager] is always there for you and has come to see me here in my room several times.”

The manager told us about the improvements put in place since they started working at the service and the action plan demonstrated the majority of shortfalls identified during our inspection had been identified by the management team and improvements were implemented or in the process of being completed.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were empowered to share their views in the service in both team and one to one supervision meetings. The staff meeting minutes March 2025 showed the provider spoke with the team about speaking out and their comments were valued, they were advised of the line of management to go to the manager or deputy initially to enable them to address any concerns and go to the provider if they felt they were not being listened to. The manager told us they operated an open door system and staff could approach them at any time. A staff member told us they felt they were listened to and their views about the service were valued and acted on.

There was a whistleblowing policy in place, which was understood.

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.

The manager told us, “We aim to treat all staff fairly and equally. Respect in a team is paramount and ensuring everyone is listened to. We held a staff session for staff to get to know each other, using prompts for conversation starters, to promote good communication and improve staff morale. Everyone has the same access to training and are able to discuss their career ambitions should they want to.”

The staff meeting minutes March 2025, a staff member had raised some staff do not like working with others, the management team advised of their responsibilities in working for the wellbeing of the people using the service. However, they were advised they could speak with management if there were concerns.

The manager told us, “Management attend the daily handover to ensure we hear first hand the challenges the team are facing so we can make decisions immediately and provide the required support to the care team."

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The manager told us they had reviewed the systems for monitoring the care provided, including developing audits, flash morning meetings, since they had been in post. The management team worked, alternate Saturdays to ensure the weekends were also monitored. A member of the senior staff was undertaking a night shift to monitor how the night shift run, once this was done they were planning to report their findings back to the manager.

Manager walk around audits were in place, these identified where shortfalls had been identified, actions were taken to address them. This included cleaning, medicines and environmental actions.

Care plan audits were detailed and showed these were reviewed thoroughly and required action to improve had been implemented. The manager understood that care plans required ongoing monitoring and had systems in place to ensure this happened.

A service improvement plan was in place which demonstrated shortfalls were being identified and addressed and showed ongoing improvement. The majority of shortfalls we identified during our inspection had been independently picked up by the management team. Where we had identified areas for improvement and shortfalls which had not been identified, the management team and provider immediately took action.

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 manager told us they had good relationships with other professionals involved in people’s care. This included commissioners, district nursing team, and the GP service, who undertook weekly ward rounds. This was confirmed by a staff member who shared examples of how joint working had improved outcomes for people, this included using guidance to review a person’s care plan when their needs had changed.

We received feedback from external professionals that demonstrated the staff worked with them to meet people’s needs in a joined up way.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

There was a programme of training provided to staff and they were reminded when this needed updating. A staff member told us how they were supported by the management team and to complete a qualification relevant to their role.

The provider’s service improvement plan and facilities plan evidenced the provider and management team were committed to ongoing improvement.

There was a programme of refurbishment being carried out, new chairs had been purchased and more to be delivered. There was new flooring ordered and due to be laid at the end of the year, this would be replacing carpets, some of which were stained. From the facilities action plan we could see the provider was financing the changes. However, we noted the walls on the ground floor and the woodwork needed attention. The woodwork such as skirting boards and door frames were chipped and the paint was no longer in place. We pointed this out to the provider, and on our second visit the maintenance staff member was undercoating the door frames and grab rails. The provider added the need for decoration onto the facilities action plan and they assured us this would be addressed fully prior to the flooring being laid.