Elmwood 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 remained 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.

Staff consistently described leadership as visible, proactive and supportive. One staff member told us, “Whatever needs doing, the registered manager stays on top of it.” Another staff member said, “Everything is positive and we have huddles [meetings] every day, they motivate us.”

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.

Management presence within the service was strong, consistent and visible across all shifts, including nights. Staff described a highly accessible and responsive approach. People spoke very positively about the management team, reinforcing a compassionate and inclusive environment. One member of staff said, “The registered manager and deputy always respond and are very visible, even on night shifts.” Another staff member told us, “Once you tell the registered manager your problems, they will solve it.”

There was clear evidence of a commitment to clinical excellence and ongoing professional development. The deputy manager had been formally recognised with a clinical excellence award, reflecting high standards of practice and having a positive impact on care delivery.

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

Staff consistently confirmed they felt able to raise concerns and speak up when needed. Feedback was uniformly positive, with staff telling us, “Yes, if I need to,” and others simply confirming “Yes we can raise anything.”

Formal and informal systems were in place to support the staff, including regular supervision, staff meetings and surveys. Records reviewed demonstrated that these forums provided opportunities for staff to share feedback, raise concerns and contribute to service improvement. Documentation showed that issues raised were acknowledged and acted upon, supporting a culture of continuous improvement and openness.

The service maintained a structured approach to complaints management. Records showed that complaints were handled appropriately, with timely responses, clear communication and apologies where required. Staff involved in complaints processes received updates on actions taken, ensuring transparency and learning.

Investigation processes were thorough and managed in line with internal policies. Evidence reviewed demonstrated that concerns were handled sensitively and confidentially, with clear documentation of findings and outcomes. Lessons learned were shared with the wider team to prevent recurrence and improve practice.

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 promoted a fair, inclusive and supportive working environment, where staff felt valued and treated equitably. Staff feedback reflected a positive experience, with one staff member telling us, “I’m treated fairly and supported when sick, the manager was very supportive.”

Management showed a clear understanding of their responsibilities under the Equality Act and described how they monitored for discrimination, bullying and unfair treatment. Processes were in place to identify and address concerns promptly, helping to ensure a respectful and safe workplace for all staff.

The workforce was diverse, and inclusivity was actively encouraged and celebrated. Staff shared examples of cultural events where food was brought in from their various cultures and traditional dress.

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. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We saw evidence of effective Governance systems in place provided clear oversight of the service and supported the delivery of high-quality care. There was a visible and hands-on management approach, with regular monitoring of the environment and daily operations. Staff consistently described this oversight, with one staff member telling us, “The registered manager checks the floors a few times a day,”

There were robust quality assurance processes in place, including audits, action plans and day and night checks. These systems supported the identification of areas for improvement and ensured actions were clearly documented, implemented and monitored. There was evidence that outcomes from audits were used to inform learning and drive continuous improvement within 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.

There were positive working partnerships with external organisations and community resources, supporting people to access services and remain connected. These partnerships contributed to people’s overall wellbeing, helping to reduce social isolation and ensuring people remained active members of their community.

Practice extended beyond the service, contributing to wider system improvement. The deputy manager acted as a ‘buddy’ within the local authority, supporting development and sharing best practice. In addition, they had been invited by the local authority to attend and contribute to clinical care training as a care home delegate, demonstrating external recognition of their expertise and the trust placed in their professional judgement.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

There was a clear approach to communication within the staff team to ensure people’s experiences were recognised and built upon. One staff member told us, “Handover tells us what people did and who visited so we talk to them about their day,” demonstrating how information sharing supported meaningful, person-centred engagement.

There were positive and proactive working partnerships with external organisations and community services. The service engaged with local initiatives, including participation in a care fair as part of Leeds Dying Matters Week, where professionals from a range of organisations such as hospices, care homes and support groups came together. This provided opportunities to share knowledge, access resources and strengthen links across the sector.