Elm Park Lodge

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 assessment we rated this key question good. At this assessment the rating has changed to 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 provider was in breach of legal regulation in relation to the governance of the service.

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 always have a shared vision, strategy and culture based on transparency, inclusion and engagement.

There was an open culture at the service amongst the staff, registered manager and managers. The managers expressed a ‘can do’ culture when we raised issues. Actions were taken following our initial findings which involved remodelling a person’s ensuite, re-commissioning a fire service assessment, and purchasing items for the home following our feedback. But the culture was not always proactive at times in terms of effectively assessing the care provided and taking independent actions to make improvements.

There were inclusive leaders at the home who understood the context in which they delivered care and support. Leaders in the home had the skills, knowledge, experience to lead effectively. But there were shortfalls with the leadership of the provider.

The registered manager and managers in the home led effectively in many ways. However, as the management team confirmed the provider was not completing any audits into the quality of the care provided. The oversight into the quality of care provided was focused solely on the registered manager. We had identified shortfalls at this assessment, in fire safety, some daily routines, audits, training, and IPC, the leadership should have identified and explored these issues. The provider was not contributing to the assessment and oversight of the service which undermined how effective the overall leadership of the home was.

There was a positive culture where people felt they could speak up and their voices would be heard.

Staff felt confident about speaking up. So did people living at the home and their relatives. The registered manager and managers also listened to our feedback and took actions following this.

The registered manager valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were diverse cultural needs in the workforce at Elm Park Lodge. Staff said they felt supported in this respect. Staff also felt supported in their careers and said they would recommend others to come and work at the home.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance.

The provider was not assessing the quality of the care provided. Nor had they commissioned a person/organisation to do this on their behalf. The registered manager was completing audits of the quality of the care at Elm Park Lodge. But we found these were not always effective. They had not identified the issues we had in terms of fire safety, IPC, training, shortfalls in care plans/risk assessments, and aspects of the day to day person centred culture of the service. The provider was not assessing the quality of the care and asking managers and staff what could be done differently.

This meant the provider had placed people at risk of harm. The provider was in breach of the legal regulation of good governance.

The registered manager understood their duty to work in partnership, so services worked seamlessly for people.

The registered manager worked with health and social care professionals. They supported people to move to new services in a healthy way.

The provider did not always focus on continuous learning, innovation and improvement across the service.

The registered manager and management team took action to respond to our concerns, and they said they would consider our findings about aspects of the culture of the home, which was positive. The management team presented as willing and wanting to fix the issues which we had found. However, the learning which should be taking place routinely was hampered by the lack of auditing by the provider and other managers in the service. A learning culture needed to develop where other perspectives were sought and worked on.