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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At our last inspection we found effective quality assurance systems were not in place to mitigate risk of harm to people. This was a breach of regulation 17 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found this had been addressed.

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.

Staff understood the principles of equality and the provider promoted a culture of shared direction. This was discussed in staff meetings and as part of staff supervision. The registered manager and staff were positive around promoting people’s rights and helping them lead a fulfilled life. There were numerous systems in place for the provider to monitor the culture of the home including feedback, regular staff training and auditing processes. A staff member told us, “Vision is to support clients as far as possible to lead a normal life and whatever their aspiration.That’swhy we are there and make sure we give as much as we can to turn their lives around.”

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.

At the time of the inspection there was not a registered manager in post. The team leader was supported by members of the wider management team. The team leader was positive around the support they received and felt they were able to ensure people received good quality care. Staff told us they felt supported and were able to voice any opinions and concerns and felt listened to. However, relatives told us they were not always sure who was managing the home in the absence of a registered manager.

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

Staff knew what whistleblowing was and how to raise any concerns. Staff felt able to voice any concerns they had and there were numerous ways the provider facilitated this. This included staff meetings and supervision. Staff also said they felt able to talk to senior management if they wanted to.

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.This was a small home with a small staff team. Staff and leaders had training in diversity and used this to help inform their staff wellbeing policy.

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.

At the time of the inspection, the service had not had a CQC registered manager for approximately a year. Having a CQC registered manager is a legal condition of the service’s registration. We discussed this with the Compliance Mentor, who was part of the senior leadership team, during the inspection. Following the inspection, we received an application for a registered manager.

Governance processeswere effective and helped to hold staff to account, keeppeoplesafe, protect people’s rights andprovidegood quality care and support. There were numerous audits which ensured the team leader was able to identify things to improve the quality of care.

The provider had a compliance team which oversaw Elm House. There were regular audits by the provider to check the quality of care. Audits included medicines, infection control, people’s care files and health and safety. These audits were monitored monthly by the compliance team to ensure any actions were competed and changes were embedded. There were further weekly audits completed by the team leader, which were shared with the compliance team to ensure continuity and accountability.

The provider invested in staff by providing them with appropriate training to meet the needs of all individuals using the service. The provider sought feedback frompeopleandthose important to them andused thefeedbacktodevelop the service.

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 home worked collaboratively with partners in people’s care to ensure services worked well for people. We saw people were fully supported to attend healthcare appointments, reviews and activities such as day centres. This allowed people to live fulfilling lives.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

At our last inspection we had found numerous concerns around the quality of care at Elm House. Since the last inspection, the provider had worked with staff and people to improve care, people’s experiences and systems underpinning care. The provider was responsive to the findings at the last inspection and had worked to improve and embed positive changes. The home had also worked in collaboration with the local authority’s Quality Team who increased monitoring of the service following the last inspection.