Elm House 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 inadequate. 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.

The service was no longer in breach of the legal regulation regarding good governance.

This service scored 71 (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.

Staff told us that morale was continuing to improve following several management changes. Staff shared the same values for the service as the managers and provider, and they were committed to providing high standards of support which was caring and person centred. Staff said they felt their views were valued and any suggestions they had would be considered and acted upon.

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.

The provider made necessary changes at management level to make sure the service was led by people with the right skills, qualities and experience. People, relatives and staff commented on the improvements they had seen following management changes and were confident in the leadership. There was now a registered manager in place, who could access further training and development to supplement their role.

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

There were appropriate whistleblowing and freedom to speak up policies. Staff said they were confident in raising any concerns or issues and knew how to do so. Staff felt the registered manager would listen to them and take any action in a responsive way.

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.

There were appropriate policies and procedures to support equality and diversity. Staff did not raise any concerns in this area.

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.

Leaders had a good understanding of risk, and staff at all levels understood their roles and responsibilities. Improvements had been made following the last inspection in respect of submitting statutory notifications to the relevant bodies, which is a legal requirement.

There was a clear governance structure. The registered manager had commenced audits of the service including environmental and clinical audits.

The registered manager conducted competencies of staff practice and monitored their performance, taking action when required.

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.

Links were made with the local community. For example, individuals from faith groups attended the home, and there were connections with local schools and nurseries. Staff and managers had good knowledge about what was available locally and developed networks so that people could access these easily.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager was committed to learning and development to improve the service, and outcomes for people. Incidents were monitored for themes and changes could be made in a flexible manner. Staff were encouraged to develop their knowledge through further training, and the registered manager intended to implement ‘champions’ for different aspects of care, such as pressure care.