The Elms 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 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 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 service was in breach of legal regulation in relation to the governance at the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the time of our assessment the provider was in the process of amending their registration to a care home without nursing.

We observed mixed morale amongst the staff. Some staff appeared motivated, for example, we observed staff spending quality time with people and this had a positive impact on people’s quality of life. However, some staff appeared disengaged and despondent, for example, some staff failed to interact with people, apart from task-based activities.

Some staff appeared to be purposefully failing to follow the provider’s protocols. For example, some staff regularly failed to close doors after use, even though we observed the home manager reminding them to do so. This placed people at risk of avoidable harm.

The home manager and the provider were aware of this prior to our inspection and had an action plan in place to address these concerns. They also held regular meetings with the staff and had involved the staff with the changes of the service.

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.

The home manager and the deputy manager were new to their roles; they recognised that there were areas where they required additional training and support to further enhance their knowledge and skills. Management appeared very dedicated and passionate about their roles and wished to make the required improvements to the service to ensure people had a good quality of life. They told us that the safety and quality of the support is the most important thing to them.

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

The provider had been working with staff to recognise the benefits of raising safeguarding concerns. Staff demonstrated they had a robust knowledge of the providers safeguarding policy and procedures, for example, they were able to clearly explain how they would escalate concerns and the action they would take to keep people safe.

We received mixed feedback from staff, whilst some staff told us they felt supported, other staff told us they were not. Feedback included, “...[Home manager], is great and has put things in place to enable me to continue to work”, and “The communication between the provider and staff is poor”. The provider was aware of this and had a development plan in place.

We saw staff had meetings with the manager following any time off work due to sickness and, where necessary, risk assessments were implemented to support staff. However, some staff told us the provider had not always followed staff’s return to work agreements to enable them to return to work safely.

The provider has access to occupational health support, and this is available for staff, however at the time of the assessment the home manager was not aware of this. The Manager told us there was an employee assistance program that included access to confidential advice.

The provider’s monitoring systems had failed to identify all the risks and shortfalls we found during our assessment. The provider was not able to demonstrate people’s care was being delivered in line with their assessed needs. Staff had not always completed people’s daily records at the time the care was given. This meant the home manager could not be assured people received care when they needed it. This placed people at risk of harm. The provider had a detailed service development plan in place, and where shortfalls had been identified, effective action had been taken, and improvements had been made. Once the provider was made aware of the risks and shortfalls we identified, they acted quickly to mitigate the risk and started to address the concerns. Time was needed before we could judge the effectiveness of these newly introduced systems.

The home manager and the deputy manager had a clear vision for the service and identified ways they were going to improve their governance of the service.

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 service was in the process of exploring ways to integrate further in the local community. There were plans to hold events in the garden and welcome members of the community as well as people attending local community activities on a regular basis.

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 management provided us with records of staff having completed mandatory training and training relevant to their role. However, many of the staff we spoke to did not demonstrate they understood the training or how to put the training into practice. For example, staff were not able to describe the consistency of food required for people who had a prescribed modified diet.

The provider was responsive to our concerns and arranged in person training for staff and introduced ways of ensuring staff had the necessary knowledge and skills in this area.

The home manager was in the process of arranging additional staff training in a variety of subjects, meaning staff will receive bespoke training that will reflect their personal learning style.