Elmbridge

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. This is the first assessment of the service. We have rated this key question 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 and culture based on transparency, equality and respect. Staff understood the provider’s values and demonstrated these in their work.

Staff said they worked well together to ensure people’s needs were met and told us there was a good sense of teamwork. One member of staff said, “We are free to give any suggestions, especially if there are any changes in the client’s needs or we need to change the care plan.”

The registered manager understood their responsibilities under the duty of candour, which is a legal requirement for health and social care providers to be open and transparent when things go wrong.

Leaders understood the context in which they delivered care and support and embodied the culture and values of the organisation. Leaders had the skills, knowledge and experience to lead effectively. They did so with integrity, openness and honesty.

Relatives said the registered manager and staff were accessible and responsive. One relative told us, “They are very accessible. I can communicate with [registered manager] or pop into the office and say what I need to say. I can ask their advice.” Another relative said, “I know I can email [registered manager] and speak to her if I am worried about [family member].”

Staff told us they received good support from the management team. One member of staff said, “We are well supported and any queries, we are free any time to ask. They are always ready to assist and advise.” A staff survey returned in February 2026 stated, 'I feel supported by the company. Management is approachable and responsive and there is clear effort to provide guidance that helps staff perform their roles effectively.'

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

Staff told us the provider encouraged them to raise any concerns they had and were confident these would be listened to. A member of staff told us, “I can speak up if I have a suggestion or concern. Managers respond well; they listen, give feedback, and take action when needed.”

Staff had opportunities to raise concerns or make suggestions at team meetings and through surveys distributed by the provider. A staff survey returned in February 2026 stated, 'The company listens to one's opinions and suggestions and makes sure you don't feel ignored.'

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 they were treated fairly and their individual rights respected. Staff attended training in Equality, Diversity and Inclusion in their induction and completed refresher training annually. Staff were issued with the provider’s Equal Opportunities policy and were trained to treat the people they supported, professionals, and colleagues with dignity and respect.

The provider’s PIR outlined how the provider supported staff in line with their individual needs, stating, ‘We currently have a very diverse workforce who all work extremely well together ensuring that they all deliver quality care to all clients. We provide adjustments to staff working patterns where possible if they require for religious purposes, such as during time of Ramadan, making sure their workload is manageable during periods of fasting, giving staff time to pray, providing time to attend church.’

The provider had effective systems for monitoring and improving the quality of the service. These supported the delivery of good quality, sustainable care.

The management team completed regular audits of key aspects of the service. Any areas identified for improvement were added to the service improvement plan. The provider used a digital care planning, risk management, and quality monitoring system, which enabled senior managers to maintain effective oversight and governance.

The registered manager completed a quality and compliance report each week which was reviewed by the organisation’s directors. Spot checks were carried out to monitor staff practice and staff had access to support through one-to-one supervision. Audits had recently identified that some supervisions and spot checks were overdue. The registered manager had put a plan in place to address this.

The management team and staff understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement.

The registered manager and staff had developed effective working relationships with other professionals involved in people’s care. Staff told us they were able to speak directly with healthcare professionals if they had concerns about people’s health or wellbeing. One member of staff said, “Twice a week a doctor comes to the Village; they have a clinic next door to our office. I have built a good relationship with both doctors and if I am concerned about a resident, I will raise it with them.”

The provider focused on learning and improvement across the organisation and local system. There were processes in place to ensure learning happened when things went wrong, and from examples of good practice. The registered manager encouraged reflection and collective problem-solving.

Staff adopted a consistent approach which included measuring outcomes and impact. The registered manager encouraged staff to speak up with ideas for improvement. There was a strong sense of trust between leadership and staff.

The registered manager ensured safety and quality was embedded in staff practice. The provider supported staff to develop their knowledge and skills, including achieving relevant national vocational qualifications.