Emmanuel House 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.

This is the first assessment for this service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 57 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff described the registered manager as supportive and committed to improving the service, and there was evidence leaders were working with the provider to secure investment in replacement furniture and environmental improvements. However, formal opportunities for staff engagement were not consistently maintained. Staff also reported limited opportunities to contribute formally to service development. These issues reduced assurance that a positive and open culture was consistently embedded across the service.

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.

Staff consistently described the registered manager as approachable and available when needed. One member of staff told us, "[The registered manager] is firm but fair." Another said, “[The registered manager] is always there to help, everyone is approachable." Staff also spoke positively about teamwork and leadership support, and we received positive feedback regarding the registered manager’s leadership across multiple staff interviews.

Staff did not always feel they could speak up and that their voice would be heard.

Staff told us the registered and deputy manager were approachable and took action when issues were brought to their attention. One senior member of staff confirmed action was taken by the registered manager when required. There were established routes for staff to raise concerns, including individual supervision and direct access to managers. However, evidence about staff confidence in speaking up was mixed. Survey participation was limited, formal staff meetings were not consistently maintained and we received some feedback that staff did not always feel speaking up would lead to change.

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 spoke positively about teamwork and support from leaders. The registered and deputy managers consideration of staff experience and skill mix when allocating staff and supporting new employees through induction and training processes. While evidence of formal equality and diversity initiatives was limited within the records reviewed, available feedback indicated staff experienced a fair and supportive working environment.

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.

We identified multiple environmental, infection prevention and health and safety concerns which had not been recognised through existing audit arrangements. Records showed safeguarding incidents had not always been reflected in CQC notification records and DoLS conditions were not consistently monitored. Several audit tools were largely tick-box exercises with limited analysis or evidence of follow-up action. The service improvement plan had identified risks and issues regarding, for example, the environment. However, the provider had failed to ensure necessary improvements had occurred in a timely manner. Although the registered manager introduced new monitoring systems following inspection feedback, governance processes had not consistently provided assurance that risks were effectively overseen.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

There was evidence of positive partnership working with health and social care professionals and historical involvement with a local nursery and with local churches. Managers were also working with relatives and external professionals to seek additional one-to-one support for people who required this. However, a lack of recent community involvement, reduced the opportunities for people to access other social opportunities.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There was evidence of a programme of improvement and digital development before our assessment, including work to introduce electronic care-management systems. However, learning and improvements were not consistently translated into demonstrable, completed action. Some audit processes provided limited analysis or evidence of completed follow-up, and identified environmental concerns remained unresolved. In response to assessment feedback, leaders introduced or strengthened a number of additional monitoring tools.