Ellis House

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. This is the first assessment for this service. This key question has been rated 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 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 clear vision, strategy and culture based on transparency, equality, human rights, diversity and inclusion. This helped staff understand what was important and guided the way care and support were delivered.

Staff told us the culture was open and honest. One staff member said, “We fully encourage family contact and families are welcome to come whenever they like. I believe that we are always honest in all things and staff feel confident to speak up.”

The provider’s values were displayed clearly on the wall in the entrance hall. The registered manager told us this helped focus staff and visitors on the ethos of the home. These values were also discussed in staff supervisions and meetings, helping ensure they were understood and used in day‑to‑day practice.

The provider promoted equality within the home. Staff photographs were displayed in the entrance hall with the heading “How can you support me?” beneath each one, outlining the strategies staff felt helped them in their roles. This demonstrated how everyone needed support at times, regardless of their position or disability, and helped to foster a culture of openness, mutual respect and equality.

A Statement of Purpose was in place, reflecting the provider’s values and aims. This helped people, families and professionals understand what the service stood for and how it intended to deliver high‑quality care.

The provider had inclusive leaders at all levels who understood the service and the people they supported. Leaders embodied the organisation’s values and promoted a culture based on integrity, openness and honesty. They had the skills, knowledge and experience needed to lead effectively and support their teams.

Relatives told us they had confidence in the registered manager’s leadership. One relative said, “I think all the management are approachable. I think it is well managed. We have family meetings.” Another relative said, “I think it’s well managed, I know all the managers there. We visit every week and talk to the staff and give our views. I think they do listen to us and do their best.”

Staff also spoke positively about the registered manager. One staff member said, “The best thing about [registered manager] is they lead by example. They will step up and work with people and won’t expect staff to do anything they are not willing to do.” Another staff member said, “[The management team] have so much knowledge, I have never worked with anyone who displays the knowledge they do. [Registered manager] always makes themself available and as well as doing their own job as registered manager will often help supporting people. The support that I have had from the management team has been incredible and I can never thank them enough.”

The registered manager used creative and inclusive methods to run the service. Team meetings took place regularly, and the manager used different recording tools to involve all staff.

The provider fostered a positive culture where staff felt confident to speak up and knew their concerns would be taken seriously.

Staff told us they felt able to raise issues openly and knew where to find information about how to speak up if they ever needed to. One staff member said, “We are encouraged to speak up if we see something. There is a sign on the wall to encourage this as well. The shift managers make time to listen if you let them know you need to talk to them.”

A whistleblowing policy was available to all staff, giving clear guidance on how to report concerns safely.

The provider valued diversity within their workforce and was working towards an inclusive and fair culture. Leaders demonstrated a commitment to improving equality and equity for staff and ensuring people were treated fairly.

Staff told us they felt respected, included and supported. One staff member described a personal difficulty they had experienced and said, “The management team listened to me and took it onboard; it really knocked me sideways due to how supportive they were.” Staff consistently reported that managers acted with compassion and fairness.

Health and safety risk assessments were completed when staff first commenced employment. Where staff disclosed medical conditions or individual needs, leaders discussed these with the staff member to identify appropriate support or reasonable adjustments. Staff told us this helped them feel safe and able to perform their roles effectively.

Overall, the culture we observed promoted fairness, inclusion and support, and staff felt they were treated equally.

The provider had established responsibilities, roles and systems of accountability. However, governance arrangements were not fully effective, and some quality audits required improvement to ensure greater oversight of staff training, medicine fridge temperatures and as‑and‑when‑required (PRN) medicine documentation.

Quality audits were completed regularly, and each member of the management team had clear areas of responsibility for monitoring different aspects of the service. However, the medicines audit lacked sufficient detail and did not fully monitor record‑keeping for PRN medicines. Staff also required further guidance on how to complete medicine fridge temperature records accurately. Training audits also required further development to ensure shortfalls were identified promptly and action was taken when staff had not completed required training. The provider had already identified this issue prior to the inspection, had created a new staff role to oversee training, and had begun taking steps to address these shortfalls. Despite these areas of improvement, many of the audits in place were detailed and covered a broad range of monitoring tasks, including care planning, daily recording, and health and safety checks.

One member of the management team told us, “The management team all support each other and the staff team. We have regular meetings where we discuss all aspects of the home.” Staff described leaders as approachable and supportive, and there was good communication within the team.

The provider understood their responsibility to collaborate and work in partnership so that services operated effectively and consistently for people. Leaders shared information, learning and concerns with relevant professionals and worked constructively to support improvement.

Visiting professionals told us that the provider communicated well with them and raised any concerns promptly. Staff also described working closely with external professionals, including disability nurses and GPs, and said they sought advice and shared relevant information to ensure people received coordinated care.

Professional involvement was clearly documented in people’s records, which showed regular communication, joint planning and follow‑up actions.

Overall, the provider demonstrated a positive approach to partnership working, supporting joined‑up care and good outcomes for people.

The provider demonstrated a commitment to continuous learning, innovation and improvement across the organisation. Leaders encouraged creative ways of delivering high‑quality, person‑centred care and worked to ensure people experienced positive outcomes. Staff described an open culture where learning was shared and improvements were routinely explored.

The provider actively sought opportunities to strengthen practice. They were members of several specialist organisations, including the British Institute of Learning Disabilities (BILD), the Staffordshire Care Association (SARCP), the National Autistic Society and the National Association for Safety and Health in Care Services (NASHiCS). The registered manager had also registered for Skills for Care’s Registered Manager Membership. They told us these memberships supported them to follow best practice, access up‑to‑date guidance and develop new approaches to support people effectively.

The registered manager responded proactively to feedback provided during this inspection and took immediate steps to address the areas identified for improvement. This demonstrated a reflective approach and a willingness to learn and adapt to maintain safe and effective care.