Ellesmere 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. 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 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.

The management team spoke with passion about the home and the desire to provide quality person-centred care for people.

Staff understood this vision and spoke about treating people as individuals.

Records of staff meeting showed these values were reinforced and staff reminded when work practises did not meet this.

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The home had a manager registered with the Care Quality Commission. They told us they felt supported by the provider, who visited the home regularly. The registered manager knew the service well and people knew them by name.

Staff consistently told us they felt supported by the management team at the home. One staff member told us about the support they had been given around a recent illness.

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

People and their relatives told us they felt comfortable communicating any concerns they had. One person said, “If I don’t like something, I can tell staff, and they will change it.”

Staff told us they felt confident they would be listened too if they raised concerns to management. One staff member told they had raised concerns in the past and the registered manager had taken immediate action.

The home had a whistle blowing policies in place to guide staff if they had concerns and staff were given the opportunity to speak up in regular supervision sessions and staff meetings. Record of staff meetings showed staff did raise concerns and actions were taken by management.

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 home had an equality and diversity policy and staff we spoke to told us that everyone was treated equitably.

Staff told us they felt empowered to make suggestions or raise concerns if they needed to. They also told us they were confident they would be listened to, and that management would take action.

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.

The provider had obtained and followed advice in relation to fire safety at the property but had failed to carryout due diligence to ensure that the consultant was suitably qualified to provide that advice. This had resulted in unsafe conditions being allowed to continue and placed people at an increased risk of harm in the event of a fire.

Audits and governance systems required improving as they had not been effective at identifying the issues we found during the inspection or ensuring prompt actions when deficiencies were found.

The home had a contingency plan for emergencies and this had recently been reviewed following advice from the fire service.

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.

Feedback from partners was consistently positive about the management of the home and the staff team. One professional told us, “Their hard work and consistency has demonstrated an improvement in the patient's condition, and they have clearly communicated with nurses to keep us informed throughout the progression of the care.”

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 management team spoke with passion about providing high quality care and how training had been developed to ensure staff had the right skills to support this. We received feedback from a healthcare professional about the support the home had given to help develop a oral care programme.