Elstow Manor

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 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 changed 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. There was evidence of regular meetings with leaders and staff where standards and goals of the service were discussed. All staff we spoke with felt there was an improved culture at Elstow Manor. A staff member said, “We were all asked for feedback and suggestions, and things have changed as a result of this. The new manager is very supportive. Back then, I made sure I had no reason to go to the office; now, I think I have been able to go in and talk to [Registered Manager]. I feel more comfortable to raise any concerns; this is a really big change. Now I can just walk in and say what I have to say.” Reflecting on their commitment to improving and maintaining quality, the nominated individual told us, "The standards you walk past are the standards you accept.” A relative told us, “I feel now the care is better than it was when [relative] first went in.”

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. Both the registered manager and the clinical lead were registered nurses. The registered manager also held relevant qualifications in health and social care management. A person told us, “Luckily there is a Clinical Lead here who is very good and I now rely more and more on [their] council, [Clinical Lead] proved to me [they are] very experienced and knowledgeable on mix of subjects.”

Leaders conducted regular audits and developed action plans focused on improving the quality of the service. One staff member remarked about the registered manager, “[Registered Manager] has built a strong team here, which didn't exist before. [Registered Manager] knows how to bring out the best in people.” A relative told us, “It feels more organised and better managed.”

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

All people, their relatives and staff we spoke with felt they could raise concerns freely. For example, a relative said, “Oh yes, any concerns, [Relative] can talk to the staff, and they are always more than happy to deal with anything [Relative] voices.”

We found evidence that the leaders had investigated concerns, and the service consistently apologised to individuals and their families in accordance with the duty of candour whenever something went wrong, regardless of how minor it was. The registered manager informed us, during the last staff survey, concerns were raised about the management team. In response, the provider ensured that the whistleblowing policy was communicated again to the staff, action plans were created, and the concerns were investigated by the senior managers of the organisation. Staff members expressed that they could utilise the provider's whistleblowing systems if they ever felt it was necessary.

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. All the staff we spoke with felt they were treated fairly and equitably. One staff member expressed, "I feel valued." Another mentioned, "Managers check in with us to see how we are doing and if we are okay." We found evidence that the service has supported staff with flexible working arrangements. We observed positive relationships among the staff team, which consisted of individuals from diverse backgrounds. The registered manager stated, "In this home, we have people working from different parts of the world, and we get along well together."

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.

During daily handovers, we observed leaders focused on accountability, provided clear direction, and proactively addressed the evolving care needs of people and the risks they could experience daily.

Leaders explained and demonstrated to us their quality assurance processes, which included monthly audits covering medications, pressure area care, infections, maintenance, and activities. We found these to be effective, and when areas for improvement were identified, they implemented and completed necessary actions. This approach helped promote safety and quality within the service. Additionally, we found quality assurance audits were conducted at the provider level, not just among the staff working at Elstow Manor.
 

The provider understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

To engage with individuals and their families, the provider shared stories and updates through newsletters and social media. Regular intergenerational activities were available; for example, a mother-and-toddler group visited monthly. Recently, the service welcomed volunteers and work-experience students. The service supported people by connecting them with community groups, such as those related to the armed services, education, and befriending services. The service participated in a community dentistry project in June 2025. This meant risks related to social isolation and closed cultures were minimised and the service had contributed to best practice and research.

The service was actively working to reduce their carbon footprint. For example, they did this by supporting local businesses and suppliers making efforts to source more local produce and products.
 

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. The provider had systems in place to identify areas for improvement and take action accordingly. For example, the provider had commissioned an independent organisation to carry out an unannounced inspection of the service to inform their quality improvement plan.

Following our previous inspection, during which we found that the service was in breach of regulations and needed improvement, the provider wrote to us to outline the actions they would take to improve. Our findings at this inspection showed they committed to taking action and improved the quality of the service. A relative told us, “I am very comfortable with the way things are now; I think it has much improved”.

Reflecting on the improvements the home has made, a staff member said, “It’s been a very bumpy journey, but it’s now been steady for a long time… it’s a totally different home.”