Elstow Manor

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

We found 1 breach of the legal regulations. The provider's systems and processes were not effective in areas such as care planning, risk management, incident recording, and managing health-related risks, which increased risks to people's health and well-being. However, staff and leaders were seen to have worked with external professionals and overall, there was positive feedback about staff and leaders being caring and approachable.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt people were treated well, and some told us they would be happy for their relatives to live at Elstow Manor. We had overall positive feedback about staff being caring and approachable. For example, a relative said, “They are friendly and helpful, and efficient. They are very kind and caring and very respectful”. There was a general consensus that the service had improved under the current interim manager.

The provider was not operating an effective strategy to ensure people living with dementia were always well supported. During this assessment, we observed some staff interactions that were not positive and were more restrictive than necessary. The provider acknowledged these findings and told us they had recruited an experienced dementia specialist and would review their dementia strategy. We will check for improvements at our next assessment. In addition to our findings about people’s nutritional needs not always being met, we observed on our first day of assessment that people who needed their food modified to manage swallowing difficulties did not have the option to have a starter with their lunch. We found some improvements had been made during our second visit. However, the soup option would not have been suitable for people needing a pureed diet due to lumps within the texture. The manager addressed this straight away when we brought this to their attention. However, we observed some positive interactions, too, such as staff respecting people’s privacy and crouching down to people’s levels to ask what they wanted to eat.

Staff felt the manager was approachable. A staff member said, “No concerns with [Manager] (the manager is) approachable, and I can have a good laugh with [manager]. Another staff member said, “[Manager] is lovely. [Manager] comes to the floor and asks if everyone is ok.” The provider told us 6 monthly wellbeing and ‘HR Clinic’ meetings were held to promote staff wellbeing and support.

At the time of our assessment there was not a registered manager in post. However, the provider managed this as positively as possible, with an experienced interim manager in post until a new registered manager started.

A staff member said there were “no barriers” in raising concerns with the manager. A director told us staff were able to whistle blow via different avenues and gave us an example of staff being able to email concerns anonymously.

The providers policies and procedures promoted the freedom to speak up.

We did not receive any feedback of concern from staff and leaders in relation to workforce equality, diversity and inclusion.

The provider's policies promoted workforce equality, diversity, and inclusion.

In response to our findings in relation to governance, the provider told us they would review and make improvements to their systems, which included areas such as care planning, risk management, accident, incident and complaints recording, medicines management, meeting people’s nutrition and hydration needs and managing health-related risks. They told us they would work in partnership with CQC to make improvements and requested monthly meetings to review their actions. CQC are reviewing this request in line with our current ways of working.

During this assessment, we identified concerns in relation to the provider's systems and processes being effective in areas such as care planning, risk management, accident, incident and complaints recording, medicines management, meeting people's nutrition and hydration needs and managing health-related risks. This increased risks to people's health, safety, and well-being.

Relatives confirmed they were kept informed and up to date. People and relatives had opportunities to give feedback, as the provider had arranged meetings to facilitate this. A relative said, “I feel very included, and I feel they care about me as well as my [Relative].”

Records showed staff and leaders had worked with external professionals such as physiotherapists and speech and language therapists.

The local authority felt the provider should have informed them of the planned improvements they had told CQC they would make following initial findings and enforcement actions from our assessment. In response to this feedback, CQC shared the providers action plans with the local authority. At the time of our assessment and writing of this report, the local authority had concerns about the service. This was due to feedback from visiting health professionals for areas such as wound care, care quality concerns raised by people and their relatives and feedback they received in person in areas such as activities on offer which had been described as “hit and miss”. We will continue to work with the provider and local authority and act on the information we receive.

In line with feedback from the local authority, improvements were needed in relation to improved communication with them. The provider was cooperative, welcoming and receptive to our feedback during this assessment.

The provider told us weekly and monthly governance meetings took place where learning was shared. The provider showed us evidence of completed actions following relatives' meetings to promote improvements based on their feedback. The provider recognised a need for improvements to be made and were committed to ensuring this.

Due to our findings in relation to accidents and incidents not always being reported or reviewed by leaders, we could not be assured learning from accidents and incidents always took place. This increased the risk of health, safety and well-being concerns not always being mitigated. The provider had not managed all complaints in line with their complaints policy. This increased the risk of improvements not being made to improve people’s experience of the care they received. As per parts of the report where this is covered in more detail, the provider had told us they would take action in response to these concerns. We will check for improvements at our next assessment.