Ellwood Place Dementia 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 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. 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. People and their relatives had opportunities to give their views and opinions. One relative told us, “The management team are brilliant, the whole team works well, they interact with us and give us feedback.” The provider ensured people were kept up to date about planned activities and events through regular newsletters. We observed people’s diverse needs and faith being considered. A number of people were supported to attend a religious service which enabled people to practice their faith as they chose.

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. People, their relatives and staff told us they felt the service was well-led. They told us when they had a complaint or suggestion they were listened to. One relative told us how they had made suggestions about different activities which were currently being considered by the team.

Staff told us they could speak with the management team. A staff member said, “We can always speak with our seniors, or the managers and I am listened to for the important things.” Regular meetings were held with managers of departments where actions for improvement were discussed. We saw planned actions were being implemented and discussed with people and staff. For example, a number of staff and relatives told us about the improvements works which had been completed in the communal living spaces, which included the creation of quieter spaces for people to use. The management team recognised staff strengths and delegated responsibility accordingly. This was in relation to staff qualification, skills and interests which made sure people received effective care.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The providers policies set out a clear process for staff to follow should they need to speak up. Staff told us they were comfortable in speaking up and gave examples when they had. Staff were able to speak with their line managers and were encouraged to speak directly with the manager whenever they wished.

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 management team ensured staff were treated with respect and were included. The service had experienced some staff turnover during the past year and some were new to the service. Staff told us how new staff were supported to join the service and how their induction included opportunities to work with experienced staff and get to know people. The workforce at the service was diverse and staff had a range of backgrounds, skills and experiences. Senior staff told us about recent improvements to induction processes to help new staff understand systems in operation and how this was communicated within the team. The service used an online rota system, which included the facility for individual and group communication. This ensured all staff were included in service updates.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. There were a range of quality monitoring processes in place which were not always effective in identifying shortfalls. For example, incidents of falls were reported, however, oversight systems did not always include information considering potential risk factors or trends which might impact the person and potential frequency of incidents. Following our feedback the registered manager took immediate action to ensure further detail was added to their reviews of incidents. Audits and checks were conducted by managers of departments and the registered manager. Findings were added to the overall action plan, which the registered manager reported to the provider. The management team were present in the service. They ensured staff were kept up to date by attending meetings, handovers and supervision which were relevant to their roles. Staff spoke highly of the management team and the direction the service was heading. One told us, “I’m confident Elwood Place is heading in the right direction. The residents are well cared for and I’m very happy here.”

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 management team was working to develop good working relationships with health and social care professionals and spoke of the links they had with health professionals, which meant people and the service received timely and appropriate support. The registered manager recognised the need to continue to work on improvements in this area. For example, to ensure the team had a clear understanding of the expectations of health professionals with regard to the details supplied within referrals to health partners. A health professional told us, “[Supporting people with dementia] is a challenging job and I have great respect for the care team who are trying their best.” Involvement from health and social care professionals was contained in people’s care records, so staff could access and follow advice. Staff handovers and meetings provided an up to date picture of how people were responding to professional input and the required changes to their support.

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. Staff and management addressed improvement actions as needed. Actions from incidents, safeguarding and audits were shared to embed a culture of learning and being open. Staff and managers welcomed and proactively learned from professionals; the registered manager and health professionals told us a number of staff had attended falls prevention training to become ‘falls champions’. A professional told us, “Following the training, the quality of the returned risk assessments improved.” The registered manager was keen to ensure this training and knowledge was available to all staff and spoke of their plans to ensure they were put forward for this training.