Elysium Care Partnerships Limited - 1a Upper Brighton Road

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 Outstanding. At this assessment the rating has changed to Good.

This meant the service was consistently managed and well led.

However, we identified the provider was in breach of a regulation in relation to good governance.

This service scored 64 (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 and managers described values of kindness, integrity and teamwork. The manager said the focus was on residents and improving quality of care. Staff described a supportive and open culture where they could raise concerns, make suggestions and speak to managers.

Managers acknowledged areas that needed improvement, including documentation, family involvement, restrictive practice and leadership stability. They described wanting to develop culture, improve person-centred care, support diversity and involve families more.

The provider had systems to support shared direction, including team meetings, management meetings, supervision, quality improvement plans and regional oversight. Staff described feeling invested in the people they supported.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and supportand embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead and had recognised areas which needed improvement.

The home manager had been in post for a few months and was supported by a regional service director, group lead manager, quality lead and specialist PBS lead. The manager described their experience, qualifications and plans to apply for registered manager status with the Care Quality Commission.

Staff described the manager and wider management team positively. Staff said managers were open, supportive, approachable and listened to concerns. Relatives also described improved communication and renewed confidence in the managers. This showed leadership was visible and responsive.

The leadership team acknowledged challenges and did not minimise them. They recognised documentation needed improvement, restrictions and monitoring needed review, and e-records would support more robust oversight.

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

Staff knew how to raise concerns and described multiple routes, including managers, speak-up guardians and escalation across services. Staff said they had no concerns about reporting and felt able to challenge or suggest improvements. One staff member said, “If I do not feel listened to, I would go to another manager.”

The manager described employee assistance and speaking-up processes, posters, emails and frequent reminders for staff. They said staff could speak to any manager and there was no blame culture, grievances are addressed and we check in with staff. Supervisions, team meetings and debriefs also created opportunities for staff to raise issues.

Relatives also said they felt able to raise concerns. One relative said they would feel comfortable calling the home and speaking with the manager or staff. Another relative said communication had improved, and they knew who to talk 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.

The manager described actively considering cultural diversity among residents and staff. They said the service supported people and staff from diverse backgrounds and wanted to develop understanding and culturally aware person-centred care.

Staff said they felt treated equally and respected. One staff member said they had raised a concern, and it was addressed immediately. Staff also described flexible working arrangements, including support around childcare. This showed the service considered staff needs and responded to concerns about fairness. The manager described values of kindness, integrity and teamwork and said the service promoted diversity to prevent discrimination. This mattered because an inclusive workforce culture supports staff wellbeing and helps people receive respectful, personalised care.

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.

The provider had a range of governance systems and processes in place to monitor the quality and safety of the service. These included quality audits, regional quality assurance visits, clinical audit schedules, quality improvement plans, management meetings, and training oversight. These arrangements supported managers to identify some risks and monitor key aspects of service delivery.

However, governance systems were not always effective in identifying, assessing and addressing concerns in a timely way. During the assessment, we found inconsistent record keeping and these issues had not been consistently identified through the provider’s existing quality assurance processes. This meant the provider could not always be assured that staff had access to accurate and current information to guide safe and effective care.

Records relating to people’s daily support were inconsistent and did not always contain sufficient detail about care provided, changes in needs or actions taken by staff. As a result, we could not be assured that important information about risks, health needs and outcomes was consistently communicated between staff teams. The continued use of multiple paper-based records contributed to duplication of information and made it more difficult to identify the most current version of documents.

Leaders were aware of some of these concerns and acknowledged improvements were needed. They described plans to strengthen record keeping and address identified issues as part of wider organisational improvements. However, these actions had not been fully implemented or embedded at the time of the assessment.

There was no registered manager in post and, although a home manager had been appointed, they had not yet commenced the registration process. This reduced management accountability during a period when the service was supporting people with complex needs who relied on staff having access to accurate, up-to-date information. Overall, governance arrangements had not consistently ensured the effective oversight of risks, records and the quality-of-care people received.

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 worked with local authorities, health professionals and internal specialist teams. Evidence included contact with epilepsy nurses, learning disability nurses, gastroenterology services, psychiatry, dieticians, independent social workers and local authority quality assurance. People were supported to attend appointments, and staff worked with families to support home visits.

Relatives described working with the service. One relative said “ We work together with staff to avoid triggers and keep my [relative] in their comfort zone as much as possible”. Another said staff communicated well about small matters. The service also contacted families after incidents, including medicines errors and health events.

The local authority had recently completed a quality assurance visit and this showed the service was connected to external oversight and engaged with community partners. These partnerships helped support people’s safety, continuity and wellbeing.

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.

Managers had identified clear improvement plans, including implementing a new care record system, reducing restrictive practices, developing a PBS champions network, improving family communication and strengthening documentation. There was a plan to create “at a glance” PBS support plans so staff could use them more effectively.

The provider used data and audits to support improvement. Experienced staff reviewed incidents, and the provider had clinical audit schedules and quality improvement plans. The organisation planned to roll out accredited PBS champion training and access to further qualifications for staff who succeeded in this role.

However, improvement work was still in progress. Restrictive practices remained in place, there were gaps in record keeping, and involving people or their relatives in care planning needed improvement. The evidence showed the provider was learning and planning improvement, but it needed to ensure these plans led to sustained changes for people.