The Elms

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 for this newly registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders did not always support the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (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.

A relative said, “The staff are very approachable and welcoming. Its home from home.”

A staff member told us, “There is good teamwork, we’re like a little family.” Another staff member said, “We work well together, and we communicate very well with each other.” Another staff member confirmed, “It is like a family home here. We all work together to do the best for our residents. I treat residents as if it was my own family member.”

Staff had a person-centred ethos, also reflected in the management of the home.

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.

A relative told us, “The registered manager and deputy manager are great. No problems whatsoever. I was able call the managers anytime. The communication is great.” Another relative commented, “The communication is excellent, and the management team are always on the ball.”

A staff member said, “The registered manager is great. They are approachable. I’ve never had to go to them, and I am able to go to [the deputy manager].”

The registered manager told us they felt supported by the provider. “The director is great. There is always lots of support from the director. They are very hands on.”

The registered manager was experienced and had worked in care for a long period of time.

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

A staff member told us, “Here I am heard. If I’ve got concerns, it would be dealt with.” Another staff member said, “If I had a concern, I know they will address it, and it would be dealt with.”

A poster advising staff to whistle blow if they had concerns was available. However, it only included an internal email address instead of a range of contact options, such as telephone numbers or named contacts. It did not reference external organisations staff could contact if they did not wish to raise concerns internally, for example national helplines, the local safeguarding authority, or CQC. The provider is responsible for ensuring accessible, comprehensive whistleblowing information is available. While staff told us they had no concerns to raise, limited information could deter staff from reporting issues in future.

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 registered manager said, “Staff have training for this. If any bullying or discrimination is happening, I would act immediately as this is not tolerated. If a staff member needed adjustments for work. We would support them with this as much as possible.”

There was an appropriate equality and diversity policy in place and records showed staff received training in this area, too.

The provider had clear responsibilities, roles, systems of accountability. However, the provider did not have good governance. They did not act on the best information about risk, performance and outcomes, or recognise failings within their service.

Systems in place failed to identify several deficiencies we identified, some of which put people at significant risk.

There were no checks on temperatures of hot water accessible to people. As a result, extreme temperatures were not identified or rectified, creating a clear risk of scalds. The provider is responsible for implementing and auditing robust hot water monitoring and for addressing residual risks without delay.

Hot pipes and other environmental concerns had not been identified, exposing people to potential scalds. The provider must ensure environmental risk assessments are comprehensive, regularly reviewed, and actions completed to reduce harm.

Omissions were present in care plans and Personal Emergency Evacuation Plans, indicating checks were not consistently effective. The provider is responsible for maintaining accurate, up‑to‑date plans and for verifying oversight processes work in practice.

Following our feedback, the provider acted swiftly to address omissions.

A person was admitted in an emergency, but the provider did not recognise they were breaching reasonably imposed conditions on their registration. The provider failed to apply to vary or remove the condition until we fed back our concerns. The provider is responsible for full compliance with registration conditions and for seeking timely variation where needed.

The provider employed a staff member in a way that did not comply with legal requirements and did not recognise this. The registered manager reported external HR support; however, relevant information was publicly available, and due diligence was not completed to verify advice. The provider acted on our feedback to resolve the issue. The provider is responsible for ensuring employment practices comply with the law and for validating external advice before implementation.

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.

A relative said, “The care home is very good at engaging with the community and the activities in the home are always available.”

A visiting professional said, “There’s nothing concerning, any recommendations we make are followed, such as the use of equipment.” Another professional told us, “Absolutely I am able to go to the [management team and staff]. I haven’t had cause to raise a concern; we have a good relationship.” They went on to tell us they felt the home worked in partnership with their organisation.

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. While we found concerns and there had been a failure by the provider to identify and address these independently, the provider and registered manager were responsive to our feedback. Feedback from relatives and staff was positive. A relative said, “I would not change anything about The Elms.” A staff member said, “The managers are very open and supportive. I feel involved with any changes that are happening, and our input and ideas are listened to.” The registered manager told us, “There is always room for improvement. We have actions plans and audits that will highlight any improvements.”