Elm Lodge Nursing and Residential 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 requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 36 (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 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.
The service had systemic problems that had not been resolved over a period of several months. The lack of follow up after multiple concerns were identified meant there was not a focus on learning and improvement.
The previous manager had failed to monitor the practice at the service which had led to significant shortfalls.
Leaders told us they were prioritizing people’s safety and internal audits had identified concerns that they shared with stakeholders. However, it was not clear that actions had been taken to address gaps. Staff acknowledged there had been a lot of changes and felt senior staff were trying their best to make improvements. The service was focusing on supporting people to enjoy their lives by improving activities and food provision at the service. Comprehensive action plans were in place to address the shortfalls at the service.
 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.
Documents were not reviewed by staff with the skills, competence and experience to do so. For example, they did not identify important information about people’s needs was missing in care plans. Staff completing audits did not have access to the necessary information for example, whether staff had been spoken to following a medication error.
Managers had not identified all the issues that we found during the inspection. However, they were dedicated to improving the skills, knowledge, experience and credibility of the leadership team to lead effectively.
Staff were generally positive about the management team and the support they received. A new manager started in post during our inspection. They were responsive and proactive in addressing issues we raised.
 

There was a lack of updates on actions taken in response to formal complaints made.
Investigation reports did not provide evidence that managers investigated concerns effectively, and that lessons were learnt and shared.
However, the provider was making efforts to rectify their responses.
The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff knew how to speak up and raise concerns and told us they would feel comfortable doing this.
Staff told us they completed surveys, had a suggestion box, attended staff meetings and had supervisions where they could share feedback with managers.
 

Leaders had identified staff that required additional support and further training particularly in relation to reporting, accessing information and using tools and guidance. However, this support was being delayed until the new home manager was in post.

Staff felt valued and that management were fair. Staff told us they had a diverse staff team with a mix of knowledge and experience. They acknowledged it had been an unsettling period with the change in management and that areas required improvement.

The provider was transparent about governance concerns and shared all the actions they had taken to improve governance systems. However, these were still being embedded, and the provider did not yet have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
Systems and processes in place to assess, monitor, and improve the quality and safety of the service provided and mitigate the risks relating to the health, safety and welfare of people were not effective. Documents were not reviewed by staff with the skills, competence and experience to do so.
Information was not up to date, accurate or properly analysed or reviewed to understand its significance. For example, insufficient action was taken following a high number of complaints, medication errors and injuries reported in November 2025.
Following audits the action plans did not always state who was responsible for the action and there was no evidence of follow up. This meant there was no assurance that important actions were being taken by the appropriate person to improve the safety of the service.

Multiple governance meetings were held, audits carried out, action plans in place. However, documentation was confusing and there were multiple different areas where information was held.
Care plan reviews did not identify that care plans did not contain suitable and sufficient risk assessments to effectively manage risks, and they were not always person centred.
The provider did not notify Care Quality Commission (CQC) of all incidents that affected the health, safety and welfare of people.
However, the provider had introduced systems, were regularly reviewing their service improvement plan and performance managing staff around recording. They advised that their priority was keeping people safe during the period of transition and that improving recording and documentation was a work in progress.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The service made referrals to health professionals when required. However, they did not fully understand their responsibilities regarding when to report safeguarding concerns and CQC notifications.

The provider did not always focus on continuous learning and did not always actively contribute to safe, effective practice.
Systems and processes in place to assess, monitor, and improve the quality and safety of the service provided and mitigate the risks relating to the health, safety and welfare of people were not effective. We found audits to lack meaningful detail to provide assurances.
There was a lesson learnt log in place. However, it was not clear that lessons had been learnt and shared with staff following incidents and complaints.
However, the provider wanted to focus on innovation and improvement across the organisation and local system. For example, leaders were involved in associations and projects relating to improving quality around workforce development and standardising competencies and training across social care.