The Elms

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 remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 representative was also the registered manager. They worked closely with the senior leadership team to take steps to ensure the provider’s vision, goals and values were implemented. In May 2024 a second registered manager was employed to help manage the service. Although they shared the provider’s vision and goals, views on how to achieve this differed. In January 2025 the second registered manager left and responsibility for the day-to-day management of the service reverted to the provider representative. This prompted a review of the provider’s strategic and business plans to ensure the service’s core business continued to be delivered.

There was an inclusive approach to further developing the service and arrangements were in place to seek feedback and ideas from people, relatives and staff.

The service was managed in such a way to ensure people could access the support the service could provide, irrespective of their social and economic circumstances. People were treated as individuals and their care and treatment planned in accordance with their protected characteristics and individual needs and wishes. The provider’s policies and procedures supported people’s human rights.

Local and geographical factors were taken into consideration when planning how the service would deliver its core business. This included its rural location, access to it by people who required care and emergency services, including access to the necessary workforce and travel to a from the service, particularly in bad weather.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Members of the senior leadership team were visible in the service and worked closely together to promote and enable the organisational vision and strategy. The team included the provider representative and a company Director. They were supported by a business administrator, deputy manager and senior care staff. These staff had the skills, knowledge and experience required to provide the overall staff team with the support and leadership they required.

Senior leaders were aware of the risks that come with a poor workplace culture, how this can impact on staff morale, staff retention and the quality of care provided to people. They had listened to feedback from staff, including people and their relatives and took action to promote a positive culture.

Staff had experienced different levels of interaction and support depending on which registered manager they had spoken with in the past. The provider representative was keen to establish stability, a positive culture and a workplace where staff felt valued.

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

Senior leaders used a variety of ways to help staff speak up. These included meetings with different staff groups where opinions, ideas, suggestions and issues could be raised and listened to. The minutes of a staff meeting held just prior to this assessment, showed staff had been reminded about how they could speak up and if they had a concern, to share this so it could be discussed and worked through. Senior leaders were visible on site and contactable off site and there had been examples of staff raising issues or unhappiness which had been listened to. A member of staff said, “If I had a concern, I know I could come to [name of registered manager] and I feel I would be listened to.”

We received mixed feedback from relatives on their experience of being able to speak up and be listened to. Most who had raised an issue told us they had been able to do this and had felt listened to. Those who told us they had found it difficult to have their voice heard in the past, felt this had improved in the last few months. They hoped this improvement would continue.

The provider’s complaints and whistleblowing policy supported ways of raising concerns or issues in a formal way. Records showed complaints and concerns were investigated and had been responded to.

Survey questionnaires were also used to gain feedback from people, relatives and staff and were another route for people to express a view, opinion and make suggestions.

One person who used the service felt able and happy to speak up for others who used the service, if they were unable to speak up independently.

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.

A values-based approach was adopted when recruiting staff to support a more equitable process. The service’s workforce had diverse needs and there was evidence to show reasonable adjustments had been made to support these. The staff rotas were being further reviewed to ensure any necessary adjustments could continue to be effectively supported. A member of staff told us they had recognised that the changes made to the staff rotas in 2024 had not always enabled this. They said, “Hopefully things will now settle.”

Staff and managers completed equality and diversity training to help them contribute to a positive workplace culture where staffs’ differences were understood, valued and supported and where each member of staff treated each other with equal respect.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to ensure good quality and sustainable care, treatment and support continued to be provided to people. They acted on information about risk, performance and outcomes, and shared this securely with others when appropriate.

Senior leaders were clear about their responsibilities, for example, to ensure processes and practices resulted in safe care, people’s care and health needs were met, and the business was managed in such a way that it remained financially viable. During the time the second registered manager was employed the provider representative had continued to have full oversight of the service on behalf of the provider. This was done by attending regular management and board meetings, being visible when on site or contactable when not on site and by reviewing and collating information gathered through various quality monitoring processes. This helped them to continue to address service shortfalls and make service improvements.

New and emerging operational and business risks also continued to be monitored. There were business continuity and emergency plans in place.

The second registered manager had introduced different quality monitoring audits and management arrangements. At the time of our assessment these were being reviewed with a view of retaining those which would enhance the provider’s existing processes.

Relevant information was shared with external agencies, including with us (CQC) in the form of notifications (as required). There were arrangements in place to keep people’s confidential personal information secure.

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.

Most relatives told us communication between themselves, and the staff was good, and they felt staff worked in partnership with them to support their relative. A few relatives commented that communication and access to information had improved in 2024 through the use of social media and supporting access to their relative’s electronic care records. The provider representative told us they would continue to look at effective and safe ways of communicating and sharing information.

Healthcare professionals told us staff communicated well with them making sure they had necessary information to support a joined-up approach to people’s care and treatment. One healthcare professional explained the arrangements in place ensured their visits were managed effectively. They said, “Staff are always helpful.” Another healthcare professional said, “We have a very good working relationship with [name of provider representative]” and commented, “Best care home in the area.”

The provider representative attended networking forums for learning purposes and ideas on service improvement. They supported their staff to do the same, for example, the activities coordinator attended regular online forums where local activity coordinators shared ideas and resources.

The activities coordinator reached out to local communities for links which would support people’s involvement in those communities. Although there were outings and external activities organised, some relatives told us they would like to see more of these taking place.

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 senior leadership team shared with us their aspirations for the service including the learning they had taken from the introduction of a second registered manager and the changes they had made. These had included for example, a new staff induction training and different quality monitoring tools. The outcomes and impact on the service from these changes were under review at the time of this assessment. The team were keen to retain changes which benefited the service. They had also reflected on initiatives which had not benefited the service.

Arrangements were in place to support staff development which in turn supported service improvement. The deputy manager was being supported to further their management skills and knowledge so they could contribute to processes which resulted in service improvement and innovation. Staff were supported to take lead roles in areas of practice or process in which they held additional knowledge so they could contribute to improvements in these areas.

Learning was taken from incidents which had not gone to plan and from reflecting on arrangements which had not worked. At the time of the assessment the provider representative reflected on the arrangements which had been introduced to inform staff of people’s resuscitation status. These were not as clear as they had wished for, so they took action to improve these arrangements.

There were arrangements in place to gather feedback from people, relatives and staff which supported ideas for service improvement and learning.