Elm Lodge Residential 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of legal regulation in relation to good governance and fit and proper persons employed; directors.
 

This service scored 29 (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 ensure there was a clear shared vision, values or culture across the service. Staff were not aware of the provider’s values, and there was no evidence these were embedded into practice or used to guide care delivery.
There was a lack of effective leadership and oversight to promote a positive and cohesive culture. Staff did not demonstrate a consistent understanding of expectations or standards of care, and there was no clear direction to support them in their roles. This resulted in a workforce that did not consistently demonstrate the skills, knowledge or approach expected within a competent and person-centred care service.
Staff told us they did not feel supported by the provider and there was limited engagement from leadership. There was no evidence of systems in place to monitor culture, support staff development or drive improvement.
Inconsistencies within the management and provider arrangements had led to a lack of stability within the service. This had resulted in ongoing gaps in guidance, oversight and support for staff, which negatively impacted the culture and quality of care provided.
 

The provider did not ensure there was consistent, capable or effective leadership within the service. Leadership arrangements had been unstable, and oversight at all levels was ineffective.
The provider was unable to demonstrate they had the skills, knowledge or competence required to lead the service safely or effectively. Leadership systems were not embedded, and there was a lack of clear direction, accountability and support for staff.
Previous management arrangements had not been supported to maintain adequate oversight of the quality and safety of the service. There was no effective supervision structure in place, and staff, including those in leadership roles, did not receive appropriate guidance, support or development opportunities.
Recruitment processes for leadership roles and care roles were not robust. The provider had not followed their own recruitment procedures when appointing a manager and senior care staff, and we identified multiple shortfalls in the process. This meant the provider could not demonstrate leaders were suitably skilled, experienced or fit for their roles.
Due to the lack of effective leadership and support, quality assurance processes were not completed effectively or accurately. Where they were undertaken, they did not identify issues or drive improvement. This meant there was no reliable system in place to monitor performance, support staff or ensure people received safe, high-quality care.
 

The provider did not ensure there were effective systems in place to support people and staff to speak up or raise concerns. There was a lack of processes, guidance and leadership to promote an open and transparent culture.
Staff told us they did not have access to consistent management support and were unclear about how to escalate concerns beyond senior staff. There was no evidence of formal processes or systems in place to support whistleblowing or freedom to speak up, and the provider did not demonstrate an understanding of how to support staff in exercising these rights.
We found no records of complaints, and incidents which met the threshold for notification to the Care Quality Commission had not been reported. This indicated a gap in systems for identifying, escalating and responding to concerns, which had not been recognised or addressed by the provider.
There was no evidence of regular staff supervision or meetings, which meant staff did not have formal opportunities to raise concerns, reflect on practice or seek guidance. While staff told us they would report concerns to senior staff, poor recording practices meant we could not be assured issues were consistently documented, escalated or acted upon.
Despite multiple concerns identified during the inspection, including environmental risks, deterioration in people’s health, and poor care practices, there was no evidence of effective escalation by staff or leadership to address these issues. This demonstrated a lack of an open culture where concerns are recognised, shared and acted upon.
 

The provider did not ensure there were effective systems in place to promote equality, diversity and inclusion across the workforce. While some positive aspects were identified, these were not supported by structured processes, training or oversight.
Recruitment records demonstrated some equitable practices, and the provider had employed a diverse workforce. Staff told us they did not experience unfair treatment or discrimination within the service.
However, the provider had not implemented systems to actively promote or monitor equality, diversity and inclusion. There was no evidence staff had received training in areas such as protected characteristics, equality, diversity, or bullying and harassment. This meant staff may not have had the knowledge required to recognise, challenge or prevent discrimination.
Systems to support staff involvement and wellbeing were not in place. There were no staff surveys, meetings or forums to enable staff to share their views or experiences. This limited opportunities for the provider to identify any concerns or promote an inclusive and supportive working environment.
These concerns demonstrated the provider had not embedded a proactive or structured approach to equality, diversity and inclusion within the workforce, meaning opportunities to promote fairness, inclusion and staff wellbeing were limited.
 

The provider’s governance systems were ineffective and failed to ensure safe, high-quality care. There was a lack of oversight, monitoring and accountability across key areas of the service, resulting in significant risks to people.
There was no effective oversight of accidents, incidents or falls, and safeguarding concerns and notifiable events to the Care Quality Commission were not consistently identified or reported. This meant reportable incidents were missed and opportunities to learn and reduce future risk were not recognised.
Audit systems were either absent or ineffective. There was no care plan audit in place, and although care plans were reviewed monthly, they did not accurately reflect people’s needs. Medication audits were ineffective and failed to identify the concerns found during the inspection. There were no systems to monitor call bell response times or to ensure people received personal care in line with their needs, such as bathing and showering.
Where audits had been completed, they were not used to drive improvement. Manager walkaround audits had identified environmental risks, including fire doors being wedged open or not closing appropriately; however, no action had been taken to address these issues. Mealtime audits had identified areas for improvement, but these had not been completed within expected timescales. Nutrition audits recorded compliance despite evidence to the contrary, demonstrating a lack of accuracy and oversight.
Environmental safety and infection prevention and control were not effectively monitored. Although cleaning schedules were in place, there were no systems to review or oversee these. As a result, the provider could not demonstrate that cleaning was consistently completed to an appropriate standard or that concerns were identified and addressed, meaning a safe and hygienic environment was not assured.
Provider-level oversight was absent. There was no evidence of provider audits, and senior leaders responsible for the service did not have access to key information required to manage the service effectively. This included staff training and competency records, recruitment processes, audits and accurate staffing information. Rotas were not reliable, and the provider could not demonstrate that enough suitably skilled staff were always deployed.
Medicines were not managed safely, and there was no effective oversight of medication practices. There were no robust audit systems in place and no checks to ensure staff administering medicines were competent to do so.
Overall, leaders did not demonstrate an understanding of adult social care regulations or their legal responsibilities. Governance systems were not established or operated effectively to assess, monitor and improve the quality and safety of the service. This resulted in widespread and systemic failings, placing people at significant risk of harm.
 

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.
Partnership working with healthcare professionals was not effective. For example, there was no evidence of engagement with palliative care services to support a person receiving end of life care, despite the service not having staff with the appropriate skills or training to meet these needs. This meant people may not have received appropriate specialist support at a critical time.
Working relationships with other healthcare professionals were inconsistent. District nurses had attended the service to provide care and treatment; however, staff were not aware of who had been seen, the reason for visits, or the treatment provided. There were no clear records of this involvement, and no evidence that care or guidance from professionals had been shared with staff or embedded into practice.
The provider did not ensure effective collaboration when people moved between services. We found no evidence of joined up working or clear communication when people were admitted to hospital, which meant staff were not informed of people’s changing needs or able to plan effectively for their return.
The provider had not supported people to engage with their local community or external services. Aside from 2 people who independently continued attending community groups they had accessed prior to admission, there was no evidence the provider had facilitated or encouraged community involvement for others. This meant people were not supported to maintain social connections or activities important to them.
Feedback from people and relatives was not used to strengthen partnerships or community links. For example, people had requested access to a hairdresser; however, there was no evidence action had been taken to arrange this. Relative surveys, where completed, had not been collated or used to identify themes or drive improvement.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.
The provider had previously received feedback and identified areas for improvement from external stakeholders. However, they had failed to take appropriate action in response. During the assessment, and following site visits, the provider did not demonstrate any learning from this feedback and had not made improvements to address the concerns identified.
Systems to support learning from incidents, audits and feedback were not effective. Accidents, incidents and safeguarding concerns were not consistently recognised, recorded or analysed. This meant opportunities to identify trends, learn lessons and reduce the risk of recurrence were missed.
Audit processes, where present, were not used to drive improvement. We identified multiple examples where audits had either not identified concerns or where identified issues had not been acted upon. This included ongoing environmental risks, unsafe medicines management, poor infection prevention practices and inadequate care planning. These concerns had not been resolved despite being identified through internal processes.
The provider did not use feedback from people, relatives or staff to inform improvement. Surveys and meetings were either not in place or not effectively used, and where feedback had been gathered, there was no evidence of analysis or action taken in response.
The provider did not demonstrate innovation or proactive approaches to improving care. There was no evidence of initiatives, service development or changes implemented to enhance people’s experiences or outcomes.
These concerns demonstrated the provider had not established a learning culture and had failed to drive improvement within the service. As a result, known risks and poor practices remained unaddressed, placing people at ongoing risk of harm and poor outcomes.