Elm Bank 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 as requires improvement.

At this assessment the rating has remained as 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.

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

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.

Although generally there was a shared vision amongst leaders and staff, we also found the provider did not always understand the challenges and needs of people and their communities.

Leaders and staff demonstrated an understanding of the provider’s vision and values to deliver high-quality, person-centred care. These values were supported by relevant policies and procedures. However not all staff knew how to access these. Leadership was described as open and transparent, fostering a positive and inclusive culture focused on continuous development and keeping people at the heart of the service.

Feedback from people and their relatives mainly reflected a positive culture within the home. However, we identified that two floors supporting people living with dementia were not particularly dementia friendly. For example, all bathrooms had mirrors, which can cause confusion or distress for some people living with dementia. One floor had plain walls, and all doors were the same colour, making navigation more difficult. These concerns were discussed with management during the assessment. Leaders informed us that both floors were undergoing a makeover, which would include dementia-friendly adaptations.

Daily meetings with heads of departments provided leaders with a service-wide overview and ensured key information was shared with staff. However, during one such meeting, concerns were raised about hot plates being too hot. Despite this, the issue persisted at lunchtime, indicating a delay in risks being addressed.

Meeting minutes were comprehensive, covering all relevant areas and encouraging staff to share feedback and ideas. Staff confirmed they were encouraged to speak up and that updates were regularly shared.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The provider, leaders, managers, and staff demonstrated a shared passion for making the care home a welcoming and homely environment. Feedback from people using the service was generally positive regarding how the service was managed. One person told us,“The manager is an absolute angel, she really is. She always makes time and comes to talk to you to ask if everything is ok.”Another commented,“I don't see an awful lot of the manager, but when I have, she is very approachable. I think the home is well run.”

The service had a registered manager in place who, following previously identified gaps by the provider , was supported by the provider, dementia leads, hospitality leads, and managers from sister homes. The manager reported feeling well-supported and stated there was always someone they could turn to for guidance.

We saw evidence of duty of candour in practice, and staff told us they felt supported and valued, contributing to a positive and inclusive workplace culture. Mechanisms for gathering feedback were in place, including a resident ambassador, regular resident and relative meetings, and surveys. However, not all residents or relatives felt their views led to meaningful change. For example, concerns raised about meals had led to improvements, but these were not consistently sustained. These findings suggest that while leadership is compassionate and committed, further work is needed to ensure that feedback leads to lasting improvements and that external support is balanced with sensitivity to peoples lived experience.

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

A range of mechanisms were in place to enable staff to speak up confidentially, and these had been further strengthened. The introduction of a‘Speak-Up Champion’had been particularly effective in empowering staff to raise concerns and share feedback. Staff spoke positively about the initiative, with one person saying,"(Staff name, ‘speak-up champion’) comes around monthly, but we can go to them at any time. I would speak up. I feel comfortable speaking to anyone." This approach has helped to foster a culture of openness, trust, and accountability within the service.

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 and leaders ensured equality of opportunity and experience for the workforce was in place. Staff were treated fairly and equally with regards to their protected characteristics, for instance flexible working patterns and privacy to observe their faith the home also has a designated prayer area. There were flexible working arrangements in place where people needed.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had systems and processes to monitor the quality and safety of the service. A range of audits and observational checks were carried out by both the provider and managers. We reviewed a sample of completed audits and found while identified concerns had actions with timescales ,not all of our findings had been identified.

Care records identified sacral wounds that may have been avoidable. Documentation of repositioning was inconsistent and incomplete, suggesting that preventative measures were either not carried out or recorded adequately. This presents a risk of harm and indicates a lack of robust monitoring systems. The findings raised concerns about the oversight, adherence to evidence-based practice, and endurance of safe care delivery.

Despite routine provider visits and manager walk-arounds, several issues identified during our assessment visit had not been detected through existing governance mechanisms. These included gaps and inconsistencies in record keeping, issues related to maintaining a safe environment, clinical oversight not being used effectively, inadequate training for staff supporting a person with a catheter, gaps in the recruitment process, and concerns around the safe storage and administration of medicines. Some action was taken in relation to staff recruitment process. Additionally, the call bell response audit did not reflect instances where staff check on a person, switch off the call bell, and return later to provide support. These findings were shared with the provider and leadership team during the assessment visit and subsequently.

A new medicines audit was completed, and some environmental concerns were addressed during the visit. However, further actions were needed to sustain and embedding the improvements required to ensure robust oversight and governance. This is essential to ensure that people using the service consistently receive safe, effective, and high-quality care.

The provider shared their action plan with us, which detailed previously identified concerns including associated timescales, our findings were added during this assessment, which had not been previously identified by the provider.

The provider had recently transitioned to an electronic care planning system, which was still in the process of being fully embedded. Additional training was planned, and support was being provided by sister homes to ensure effective implementation. During this assessment visit we observed some improvements in the use of the system; however full embedding was required to ensure consistent and effective practice.

A contingency plan was in place for emergencies, including procedures for the evacuation of the home.

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 service has a resident ambassador in place who plays an active role in gathering and representing residents’ views. This supports a culture of inclusion and person-centred care. The home hosts regular‘ Dementia Cafés’, fostering community engagement and providing a supportive space for people living with dementia and their families. The service also maintains strong partnerships with external organisations, including Age UK, and has established positive working relationships with GPs and district nurses, contributing to coordinated and responsive healthcare support.

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.

The provider, managers, and staff demonstrated an understanding of the importance of learning from incidents, audits, and feedback as a means to improve the service and enhance people’s quality of life. We saw evidence that learning was shared with staff. However, this learning was not always consistently applied in practice. For example, concerns about lunch plates being too hot were raised during a stand-up meeting, yet the issue persisted the following lunch time, placing people at continued risk of harm.

We also noted positive initiatives, such as the role of the ‘resident ambassador’ who effectively advocated for people’s views, with outcomes and actions shared transparently. The service maintained good links with local community groups, and the registered manager described their involvement in both local and national initiatives, including hosting weekly Dementia Café coffee mornings at the home and attending external community events.

These findings suggest that while the service is committed to learning and innovation, further consistency is needed in applying learning to practice and addressing operational barriers to improvement.