Elmsdene 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 requires improvement.

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

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

We saw an appropriate strategy and vision, and the manager led by example. Managers told us they shared the vision of the service with staff through regular staff meetings, and policies and procedures were also discussed. Managers led with an open-door policy and staff could access support as and when they needed it.

Not all leaders understood the context in which they delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

After the assessment we were made aware of significant changes made to the governance structure for the home, to make sure that leaders had the right skills, knowledge and experience to lead effectively. Changes needed to become embedded.

The service 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 confirmed they were confident in raising any concerns or issues and would be listened to.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Appropriate policies and procedures accounted for workforce equality, diversity and inclusion. Staff said they did not have any concerns in this area.

The service did not always have clear responsibilities, roles, systems of accountability or good governance.

Recent management arrangements had not worked out, and therefore the provider had made changes to the governance structure, which we were advised of some weeks after the assessment. The home was without a manager who was registered with the CQC.

The provider undertook audits of the service, although there had been a 2-month gap to some audits owing to the changes to the management structure. This was resolved after the assessment. Although staff undertook medicine audits, issues found during the assessment had not previously been identified. The provider told us this would be addressed when we raised it.

At the time of the assessment, we could not see an effective system to collate safeguarding concerns, meaning any actions recommended by the safeguarding team could have been missed and not implemented or monitored. Additionally, although staff documented incidents, we could not see what the system was to oversee these, identify themes and patterns, learn lessons and make changes where needed. This was a lost opportunity to improve care. We were advised that incident analysis had re-commenced after the assessment and the provider sent us evidence of this.

Although the provider was aware of their legal duty to make statutory notifications to the relevant body, we found gaps in the reporting of some types of incidents. The provider submitted these after the assessment.

Management needed to make sure that staff followed correct processes around obtaining consent, and the use of bed rails.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

There was good integration with external health and social care departments and information was shared effectively. Staff worked with other agencies well such as social workers, falls team, district nurses and the local mental health teams.

The service 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 contribute to safe, effective practice and research.

Managers and staff said they were committed to continuous improvement and participated in external training and conferences. Staff were encouraged to undertake further learning and development to widen their knowledge and skills.