Elm 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 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 and leaders were passionate about their work and showed a commitment to improving the lives of the people who lived at the care home. All staff completed mandatory training which reflected the values of the organisation, with person-centred care, dignity in personal care, hate crime awareness, learning disability and autism awareness, and mental health awareness modules. This showed the provider was committed to ensuring all staff had a shared understanding and values. The provider’s policies and procedures also reinforced the values of the organisation, with all staff being asked to read and sign to confirm they had read these documents.

The values of the organisation were described on the provider’s website and in their statement of purpose, and we observed the care and support reflected these values.

One relative told us, “They treat [person] like they are one of their own. I would give them 100% for care”.

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.

The registered manager and other leaders spent time delivering care and interacting with people, so there was a mutual respect between staff and leaders. This meant communication was open and leaders were approachable if anybody had concerns.

Supervisions and appraisals were completed on a regular basis, so staff had an opportunity to talk about their development and raise any concerns they may have, in a confidential setting.

Leaders interacted with people in a compassionate way, adapting their communication style to meet the needs of the individual. For example, by kneeling down and holding hands with one person who was sitting down, or by having a laugh and a joke with another person who was making a cup of tea in the kitchen. This showed they knew people well and people found leaders approachable.

One person told us, “They are very nice, I can talk to them”. A relative told us, “The managers are lovely”.

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

Posters which informed staff about how to speak up were on display around the building, and staff demonstrated a knowledge of speaking up and how to do so when we spoke with them. The provider had a whistleblowing policy in place which had a clear procedure which described the steps a staff member would need to take in order to raise a concern.

One staff member told us, “I can go to the registered manager if I have any problems, they have been great”.

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 had a diverse group of staff who told us they felt they were included, respected and treated equally. In a recent staff survey, all staff responded with an “Outstanding” response when they were asked if they received training and development in a method which suited their individual needs.

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 provider had strong systems and processes in place to ensure good governance in all areas. The provider placed great value on documenting information, and the level of recording ensured analysis of any concerning trends could be completed. For example, diet and fluid charts were completed accurately for people who required monitoring. This meant if they were showing signs of malnutrition or becoming overweight, there were clear records of the person’s food and fluid intake. This helped the provider to take action to support the person to meet their needs in this area, or to support healthcare professionals such as the GP to make informed decisions about people’s care.

Leaders completed regular audits covering all aspects of the running of the care home, from medication audits, accident and incident reports, maintenance checks, and IPC checks. When concerns were identified, the provider identified actions to address the issue. This showed the provider was looking to continuously improve and be proactive in spotting potential issues before they became major concerns. For example, a recent incident had been recorded, and leaders had completed a, root cause analysis document. This contained information on contributing factors, the root cause, the immediate actions taken, lessons learned, and recommendations. This was then followed by an action plan where a staff member was identified as being responsible to ensure the plan was carried out, and a timescale for this work being completed.

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.

Care plans were informed by information gathered from people, their families, and partner organisations such as adult social care and healthcare professionals. This showed the provider took a joined-up approach to people’s care, valuing the contributions of everybody involved in people’s care.

Leaders understood the value of involving external professionals with expertise to improve people’s lives. Referrals had been made to partner agencies such as mental health teams, SALT teams, nursing teams and advocacy organisations. Each person’s care plan contained details of all of the agencies involved in their care and an explanation of what role these agencies played. This meant staff who had not directly dealt with those agencies before would understand why they were involved and what they could contribute to people’s care.

People attended a wide range of day activities and community groups, and leaders maintained good relationships with these organisations. This helped to ensure communication was good and people benefited from regular activities in the community.

An external professional who worked with people at the care home told us, “The registered manager is easy to contact and very helpful”.

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.

Leaders had put robust systems in place for documenting people’s care and support. This meant there were accurate records which enabled leaders to analyse and reflect on learning. Incident reports and audits contained prompts which focused on learning from incidents, with action plans, designated staff to carry out actions, and timescales identified. This meant learning and taking action was embedded in processes.

Leaders ensured staff received training so all staff had a good grounding of knowledge. Supervisions and appraisals were used as opportunities for staff to identify any learning opportunities, with leaders supporting staff to receive extra training which was relevant to their role. In addition to mandatory training, staff were supported to gain care qualifications for their personal development.