Elliott 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 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 good governance.

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.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. Although some staff were unsure of the vision or strategy of the service, all staff told us they felt valued and enjoyed working at the service. However, there were restrictive practices in place which limited people’s freedom including locked kitchen and laundry room doors and a locked kitchen drawer in the main house. The provider had not fully considered or assessed the impact of imposed restrictions to people, for example mental capacity assessments were not decision specific and did not evidence the impact that these restrictions would have for individuals. Where restrictions were in place within the annex, documentation did not evidence how the decisions around restrictions in place were made or whether they were the least restrictive option.

Leaders did not always have the skills, knowledge and experience to lead effectively. The registered manager did not always demonstrate they were able to implement best practice guidance in relation to Infection, prevention and control, Mental Capacity Act (2005). This had a detrimental effect on the quality and safety of the service resulting in breaches of regulation. However the Manager was visible at the service, and staff spoke highly of them. Staff told us “The manager leads by example, which is a sign of a good leader, she has a lot of experience and comes from a care background, she has worked her way up from the bottom to the top”.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had policies in place to enable staff to speak out, such as the speak up policy. Staff told us they felt confident to speak up. For example, comments included, “Something that encourages staff to raise concerns around poor practices, bullying or harassment or any breach of our values and policies in the house. We have regular meetings, and we always talk about these things with all the staff” and “The manager remembers anything we raise and encourages openness. We all help each other and can voice any worries we have.”

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. Staff told us, “The manager treats everyone equally and there is no bias” “The team is very good; we always support each other and never feel lonely.” Staff and leaders told us of reasonable adjustments that had been put in place to support staff to continue their role.

The provider had policies in place including equality and diversity and flexible working. Staff had completed equality and diversity training.

The provider did not always have effective systems for identifying, capturing and managing organisational risks. Although the provider had various audits including a service review, the audits completed had not identified all of the issues we found at this inspection in relation to medicines, safe environments, infection, prevention control, managing risk and restrictive practices. Where staff completed health and safety audits and issues were documented there was no evidence of actions taken and whether these issues had been resolved. Evidence of areas being checked were not always completed so we could not be assured that these checks had taken place including the external areas where we had identified concerns during our inspection posing a risk to people using the service. Health and safety and infection, prevention and control audits had not been signed off by the Manager, therefore we could not be assured that the manager had oversight of any concerns highlighted. Blanket restrictive practices were in place within the main house and mental capacity assessments were not decision specific in relation to these restrictions. The provider was in breach of 3 regulations.

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. One professional told us, “I am kept abreast of any significant issues that may arise between the annual reviews, and I am included in annual mental capacity assessments (MCA) updates.” One person was anxious around attending dental appointments. In response, the provider organised for a dentist to visit the service to minimise any distress. The registered manager told us that people attend events within the organisation including, VE day, Easter parties and Choice has got talent enabling friendships to made in a broader way.

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. For example concerns identified in previous inspections relating to restrictive practices had not been fully implemented, embedded and sustained. The provider and staff worked with stakeholders and agencies, to support the provision of people’s care. Feedback, regarding people whose predominant needs related to their learning disability were positive overall. One professional told us “In the autumn of 2023, I contacted the CEO of Choice Group to give feedback on how impressed we have been with the care support provided to [name] over the years the progress made. A response was received from the CEO acknowledging my letter and this resulted in the registered manager the Elliott House team receiving the CEO Award at their annual awards ceremony at the end of 2023”.