Elmcroft 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 inspection we rated this key question inadequate. At this inspection 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.

At our last inspection the provider was in breach of the of legal regulations in relation to good governance. Improvements were found at this inspection, and the provider was no longer in breach of this regulation.

This service scored 71 (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. The management team worked in collaboration with people, relatives and staff to develop and embed a shared vision for the service. The service’s underpinning values were co-produced and reflected what was important to everyone in the service.

Staff understood their roles and responsibilities and felt involved in decision-making. Staff told us they felt proud of the service and the care they provided. Comments included, “I genuinely enjoy spending time with the residents, making the service feel as homely as possible, and continually thinking of new ideas to enhance their quality of life” and “We are united and work as a team; it doesn't matter which department you are working in, we always come together to assist our residents.”

People’s relatives spoke positively about the improvements in the culture of the service. Comments included, “The home has come so far”, “We feel like our family is really cared for”, “[There are] improvements all the time”, “I feel very welcome” and “The staff are all so caring and make [person] feel like it is their home and make me feel like it is [person’s] home and our home.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care 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.

People, relatives, staff and professionals spoke positively about the registered manager and wider management team and the significant improvements in the service under their leadership. They told us the registered manager was visible, approachable, supportive and led by example.

Comments from people’s relatives included, “Everything is in order and in place and underpinned to do the best thing for the people in their care. They have the right people in place to do this”, “They are responsible and it is run professionally”, “[Registered manager] is 100% a very caring, decent, no ego, genuine person, I would be worried if they didn’t have a manager like them” and “It feels like it is being led by someone who cares. The staff are following on from [registered manager’s] example. The staff turn to [registered manager] for guidance.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were listened to and able to give feedback. Staff told us they felt comfortable raising concerns and were assured the management team would respond appropriately. Staff had access to policies and processes to support whistleblowing and speaking up.

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 provider had policies in place to ensure equality in their recruitment and training opportunities. Reasonable adjustments were in place where appropriate and staff were able to request any additional support they required to fulfil their role.

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

The registered manager and management team had implemented a wide range of governance audits. However, we found some areas where improvements in oversight were still required. For example, in person-centred care planning, risk management, recording people’s consent and addressing concerns with staff communication. The registered manager and wider management team were aware there were areas where further developments were still required. They told us they were continuously reviewing their governance processes to monitor impact and drive improvements.

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 provider worked in partnership with a wide range of health and social care professionals. The registered manager demonstrated a strong commitment to fostering positive working partnerships. Feedback from health professionals reflected the significant improvements in partnership working under the current management team. One health professional told us, “In the past I would not be able to call the care home as the phones were not picked up, now they are regularly answered, and the admin staff are friendly and helpful”, “The manager asks for feedback and will also as be seen walking around the care home checking on residents and staff” and “I would absolutely say there have been changes for the positive.”

The provider demonstrated a commitment to continuous learning and improvement. The management team encouraged people, relatives and staff to be involved in making decisions about the service and managers were responsive to feedback from other health and social care professionals.

Following our last inspection, the management team had implemented an ongoing service improvement plan to demonstrate how actions were being prioritised and addressed. At this inspection, we found significant improvements had been made. However, we also identified some areas where improvements were not yet fully embedded. The management team responded promptly to our feedback, confirming they were reviewing their service improvement plan to better evidence how improvements were monitored and evaluated.