Elton Hall 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 requires improvement. This meant the management and leadership was inconsistent.

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

This service scored 61 (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 and their communities. The provider communicated its vision and values to staff and people who used the service. Staff told us there was a positive culture in the home and that managers supported them to achieve this.

The home had not consistently had capable, compassionate and inclusive leaders. Provider oversight of the home had not ensured consistency and continuity, and we found issues in relation to governance. While new management were proactive and both relatives and staff told us they felt they were caring and inclusive, some issues in the home had been ongoing and had not been identified or addressed by the provider.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Policies supported staff to speak up, providing routes for anonymous concerns as well as signposting them to external agencies. Staff told us they felt confident to speak up. A staff member told us, “I am comfortable to express any opinions I may have."

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. Recruitment processes, training and policy and procedures were in place to support equality, diversity and inclusion. Staff told us they felt they were treated fairly.

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.

There were quality systems in place in the home and audits were completed. However, when we visited for this assessment, we found issues with the premises, medicines and with records that had not been either identified or addressed by the provider. Some of these issues had been ongoing and had not been addressed in a timely way. There was a very new management team in the home who were working proactively to identify and address issues. They were responsive to the issues found and either rectified these immediately or gave assurances about making improvements.

Feedback about the new management team was positive and people, relatives and staff told us management were approachable and responsive. The home was working to an improvement plan and had welcomed other agencies into the service to help them make and sustain changes. The provider was supporting the home with assistance from the wider management team.

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 had links with the local community and had made recent links with community and charity groups for the benefit of people in the service, for example work was ongoing with an organisation supporting people with dementia and another group supporting veterans.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. We also identified a breach of regulation in relation to good governance. As such, the provider’s governance processes had not consistently introduced or sustained improvement.