Archived: Elizabeth House

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. The service had a ‘mission statement’ which set out the core values of the service. Conversations with the manager and staff confirmed they upheld these values and worked together as a team to provide care and support to people.

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.

At the time of this assessment the service did not have a registered manager in post. However, the provider’s regional manager (and former registered manager of Elizabeth House) had taken over the day to day running of the service and had submitted an application to re-register with CQC which was in the process of being assessed. People spoke positively about her return to Elizabeth House and ability to manage the service. One relative told us, "They have had a few managers in the last year or two, but [manager name] is very good. It did slip a bit when she wasn’t here, so I am very glad she is back." We found the manager to be knowledgeable about the service and the people living there, and to be very motivated to provide the best care they could.

The provider promoted a positive culture where people felt they could speak up and their voice would be heard. One person told us, "I know the manager, she is easy to talk to, and I would be comfortable discussing any problems." Another person said, "The manager is easy to talk to. I can have a laugh with her as well." Relatives also felt able to speak up. One told us, "I have spoken with the manager a few times. I've no problems and any questions I've had have been answered." Another relative said, "If something is wrong, they [staff] put it right and I do think they are proactive here. [Manager name] is easy to talk to and I get on with her. I think the home runs better when she is the manager."

People were able to provide feedback and ideas about the service through meetings and surveys and were regularly asked their opinion on the quality of the food and activities. The service operated a ‘resident of the day’ scheme which aimed to improve person-centred care at the home and gave staff the opportunity to focus on each individual person, review their care plan and discuss their care needs and support. The manager told us they had an ‘open-door’ management style so people, relatives and staff could approach them at any time. The service had a whistleblowing policy which provided staff with guidance about raising concerns.

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. Support and reasonable adjustments were made for staff when needed, for example if staff experienced personal issues or for medical reasons. The provider employed staff from diverse backgrounds and was happy to make adjustments to their working patterns to fit in with their personal circumstances and spiritual and religious observances. Staff told us they enjoyed working at the service and felt supported by the manager.

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. People and staff spoke positively about the manager’s return to the service. The provider had made improvements since our last inspection and the service was no longer in breach of regulations. Governance systems were in place with regular audits and checks completed. The manager told us they were well-supported by the provider, who visited the service regularly.

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. Care records contained evidence of partnership working and showed advice from external healthcare professionals was sought and acted upon.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. Accidents and incidents were reported and investigated and any lessons learned shared with staff during meetings and daily handovers. Staff received regular training and supervision and all staff we spoke with said they were happy with the standard of training.

Monitoring of the service was carried out through regular auditing and the development of an action plan which was continually updated. All care records were created through an electronic system which staff accessed through hand-held devices. The manager told us they attended weekly meetings with the software developer to discuss any problems with the care documentation system.