The Elms

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

The service had made improvements and are no longer in breach of the regulations. The provider had improved their quality monitoring systems to help them identify any shortfalls in the management of people’s care and the running of the home. There was a positive and open culture The provider used feedback from people, staff and other professionals to drive improvement. Staff praised the managers and told us they were approachable and listened to their views. The registered manager and staff were open and honest with people and their relatives when people when things went wrong. Staff were encouraged to reflect and consider any learnings after any incidents to help prevent further incidents.

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 registered manager had a clear vision to deliver good quality and person-centred care which was inclusive and promoted people's human rights and independence. The registered manager led by example and focused on learning from incidents and feedback from people to drive improvement across the service. Staff were aware of the provider's expected standards and values of putting people first and focusing on people's individual needs. They told us the staff team worked well together but were not afraid of raising any concerns.

The provider valued people's feedback and acted on their suggestions such as introducing a more varied menu or different activities based on people's ideas. We observed and heard positive interactions between people and staff which truly embodied the values and goals of the provider. There was evidence of local and community engagement and regular meetings with people and their relatives and staff to hear their views and experiences of the service.

Staff complimented the management of the home and told us they felt there was a strong staff team who worked well together. They were confident that the managers had the skills and vision to lead the service and deliver good quality care. We were told the managers and senior care staff team were both professional and approachable. It was evident that the registered manager knew people and staff well and where knowledgeable about areas of the home that required further development.

Strong communications systems were in place to ensure staff had the information they needed to support people safely. The registered manager also carried out unannounced out of hours visits to the home to check that standards of care were being maintained. Where poor practices were found, appropriate disciplinary measures were taken with the staff members involved. The provider had appointed leads in specific areas to assist in promoting and enhancing the service such as infection control. A business contingency plan was in place to help safeguard the home and reduce the impact on people in the event of disruption to the service.

Staff spoke positively about the managers and confirmed that they were approachable and listened to their views and personal requests. Adjustments were made to support staff's personal well-being and circumstances. They told us the registered manager was responsive, open and staff felt valued. The registered manager and staff were aware of the importance to speak up and act with honesty and integrity when they observed poor practices or when things went wrong.

The provider promoted a positive and inclusive culture to enable people, relatives and staff to voice their concerns without fear of repercussions. The registered manager investigated any concerns or allegations and reported them to the relevant authorities as well as reflecting and take learning from any incidents. Staff were given various opportunities to raise concerns and we saw evidence of staff meetings and sharing of good practises. The providers policies and procedures supported an open and transparent culture with the aim to drive improvement across the service. Meetings with relatives and people were held to enable them to raise, discuss and resolve any concerns with staff and managers.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us that they felt supported and valued by the managers. Staff reported they had seen improvements in the working arrangements at the home as well as the oversight and support from managers. They said additional systems had been implemented to monitor the quality of care being provided to people such as audits to monitor the cleanliness of the home. Regular staff and departmental meetings were held, to enable important information to be shared amongst the staff team.

The service had made improvements and are no longer in breach of the regulations. The provider had reviewed their governance systems to ensure they were effective to help the provider recognise shortfalls and drive improvement. The provider was committed to working in a collaborative and inclusively with people, families, staff and key stakeholders to ensure the home's standard of care were being continuously met. Managers were passionate about delivering high quality service. They provided staff with support and guidance on expected care standards and led by example. The provider had taken action since our last inspection and had enhanced their quality monitoring systems to help them identify any shortfalls in the management of people’s care. We were shown copies of internal and external monitoring reports. Areas that required further improvement were recorded on the provider's service improvement plan. Staff and managers understood their role and responsibilities and to report any concerns to the appropriate managers or other external agencies. There was evidence of out of hours leadership and support.

People's relatives were positive about the communication from the home and felt there was a professional but friendly working relationship between them and the staff and managers. Relatives told us they received regular emails and newsletters from the home keeping them updated. One relative said, "I have had nothing but positive responses from all the care staff….Always eager to help, in my view they are all very positive. "

Staff spoke positively about people and enjoyed engaging and greeting with people when they came on shift. They worked in partnership with people and involved them in the planning of activities. Staff supported people to attend bus trips for example to the library and events in the local area. Staff told us about networking with the community to improve and grow local community relationships such as visits from children from the local primary school at Easter and Christmas. Staff reported improvements in the management of people's medicines since working with their local pharmacy.

Health care professionals spoke positively about the care being provided at The Elms. They complimented the dedication of staff and their organisational and communication skills. The home's partners told us staff were very engaging and responsive to their recommendations.

The registered manager shared examples of working openly and in partnership with key organisations and professionals, to support people's care provision and to develop the service such as working with the local GP and pharmacy. The provider worked in partnership with other health care professionals when best interest meetings were required to make specific decisions about people's care. The provider valued people's feedback and provided opportunities to receive feedback about their experiences of the home through resident meetings and surveys. The provider worked inclusively with local communities and colleges.

Staff spoke positively about the learning culture of the home. They had been given opportunities to speak and reflect on incidents to help them improve their practices and share any learnings. The registered manager and staff were aware of the principles and importance of duty of candour and to be open and honest with people and their relatives when people had been harmed or distressed.

The provider was proactive and had worked in partnership with external organisations to improve the home's practices. For example, we saw evidence of the provider working with the local dementia team on a project to improve the dementia diagnosis rate in the local area. The provider carried out different methods to ensure staff understood their role such as quizzes, carrying out additional training, and attending conferences Feedback from people and their relatives via surveys and meetings helped the provider to understand people’s experiences and make changes where necessary Accidents and incidents were reported and recorded. Staff were supported to reflect on incidents and actions were taken to address any shortfalls to help prevent future incidents. This demonstrated the provider had a proactive approach to help prevent future incidents.