Elm House 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

There were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care. We found breaches of the legal regulation (governance). Not enough improvement had been made in the governance of the service following the previous inspection in October 2023. There were insufficient systems and processes to make sure risk was identified, mitigated and managed. Although there had been improvements in staff morale and staff culture, the management structure did not provide effective leadership and guidance to staff. However, there were appropriate policies regarding whistleblowing, and equality and diversity. Staff said they felt able to speak up about any concerns they had and thought the team worked well together. Although the service worked in partnership with local partners, we could not see how managers made sure they kept up to date with current practice and continually improve the service.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from staff was positive about morale and culture in the home. We noted some positive and caring interactions, however we were concerned that staff had not made sure that people had the right medication when they needed it.

There was a business plan and contingency plans in place. The provider commenced recruitment of leaders to effect changes and improvements to the service.

Staff said senior staff and the provider were approachable and supportive.

The service had experienced several changes of manager for various reasons, and had been without a registered manager for some time. This resulted in a lack of governance and oversight to the service.

Staff told us they felt confident in speaking up about any issues or concerns, and said they felt listened to.

There were appropriate policies in place and the provider planned to meet with staff to promote openness and transparency about the concerns raised during the inspection.

Staff said they thought the service was fair and equitable and had not noticed any discrimination.

There were appropriate policies to support equality and diversity, and fairness to staff.

Staff said they were not always included in things like putting together care plans and risk assessments. Senior staff said that at times they did not feel supported to widen their knowledge and skills to effectively undertake their role. This was being addressed with the implementation of a new management team.

For various reasons, the service experienced several changes in management, and there were significant gaps in the governance and oversight of the service. The home had been without a manger that was registered with the CQC, which is their legal responsibility to do so. There were gaps in monitoring health and safety outcomes; we did not see any evidence of audits which was a lost opportunity to identify problems and make changes. Systems had not identified concerns that were noted during the inspection, for example shortfalls in medicines management, and gaps in risk assessments, care plans and consideration of consent. Processes were not in place or ineffective, for example to monitor incidents and safeguarding concerns, and to make sure people were admitted into the care home safely. This was a breach of the legal regulation (governance). The service was being supported by partner agencies to make improvements and established an action plan to show what would be done and by when to support change.

Staff did not have any feedback in this area. Leaders told us of examples of working in partnership such as with local mental health teams and social workers.

It was unclear what the processes were to support effective partnership working.

Staff confirmed that some monitoring of outcomes was missing due to moving to an electronic system. This meant there was a risk improvements would not be made.

There was a lack of systems and processes to make sure problems were identified to learn lessons and make necessary changes to improve. It was not clear what was in place to support senior staff to develop their knowledge and skills, to promote improvements and innovations.