Elm Tree 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. These values were embedded within the culture of the service and reflected in the way staff delivered care and support.

Leaders monitored how these values were put into practice through observations, quality assurance walkarounds, staff meetings and supervision sessions. Quality walkarounds included speaking with people to gather feedback about their experiences and observing interactions between staff and people to ensure care was delivered in line with the provider’s values.

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. They did so with integrity, openness and honesty. Staff spoke positively about leaders and described them as approachable and supportive.

Leaders had the skills, knowledge, experience to carry out their roles effectively. The registered manager told us they had completed training relevant to their role, including leadership qualifications, and were committed to their ongoing professional development. At the time of the inspection, they had applied to undertake further management training. Leaders explained that the provider actively supported continuing professional development, with training opportunities approved and encouraged by senior management.

Managers received additional support through workshops delivered by human resource colleagues, including updates on changes in legislation and best practice. Attendance at these sessions was mandatory for managers, helping to ensure leaders maintained their knowledge and skills.

The provider had arrangements to support effective leadership continuity. The deputy manager had been provided training and support to ensure they could provide effective management support in the managers absence.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had a designated ‘Freedom to Speak Up’ champion who provided staff with an additional route to raise concerns or share feedback. Leaders also promoted the provider’s whistleblowing policy and encouraged staff to speak up about any issues affecting the quality or safety of care.

A positive culture pledge set clear expectations about behaviours, values and how people and staff should be treated. This helped to reinforce an open, honest and respectful culture throughout the service.

Leaders also held quarterly staff forums where staff could discuss any issues, concerns or ideas for improvement. These meetings were delivered online to maximise attendance and participation. Feedback from people and staff was shared across the organisation through forums and ‘You Said, We Did’ initiatives. This demonstrated leaders listened to concerns and suggestions and took action in response, helping to create a culture where people and staff felt valued and empowered to speak 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. Leaders said flexible working arrangements were available where possible, including support for staff with caring responsibilities, childcare commitments and health needs. The manager described how individual arrangements were considered and implemented to support staff wellbeing and enable them to continue working whilst balancing the needs of the service. The provider also respected and accommodated staff members’ religious beliefs and practices. For example, when staff requested a suitable space for prayer, arrangements were made to support this.

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.

The manager now had systems to ensure effective oversight of the service.

For example, the manager completed a comprehensive monthly report and action plan and then submitted this to senior managers for their oversight. Audits included incident trends, health and safety checks, feedback from relatives and people and staffing information. Additionally, senior managers complete quality walkarounds, seeking feedback from people and observing practice.

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.

Leaders confirmed how they worked in partnership with others to achieve good outcomes for people. The manager said the service made referrals to health and social care professionals to achieve good outcomes for people. For example, one person had recently had a review and increase in funding to ensure their needs were met appropriately.

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.

The service had systems to identify learning, and drive improvements across the organisation. The manger and deputy manager took part in regular safety huddles with staff following incidents. Leaders said serious incident reviews were held with managers and senior leaders. These meetings were used to examine incidents in detail, identify any missed opportunities and agree actions to reduce future risks. Examples included reviews of serious incidents such as fire and a missing person. Learning from these reviews were shared across the organisation, providing oversight and promoting consistent learning between the provider’s services.

Staff were encouraged to contribute ideas to improve people’s experiences and the service environment. For example, suggestions to install air conditioning and identifying the need for a dedicated disabled parking bay to ensure access for the home’s vehicle and emergency services.

The provider supported regular communication and shared learning through team briefings, manager meetings, and weekly catchups. These forums enabled managers to share good practices, discuss challenges, and learn from each other’s experiences.

The service also kept up to date with changes in legislation and best practice. For example, additional training had been arranged for managers in response to recent changes relating to the Deprivation of Liberty Safeguards (DoLS)