Elmhurst 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. This is the first assessment for the newly registered provider of this service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulations relating to good governance.

This service scored 25 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. The provider did not have an effective or shared vision or strategy that was based on transparency and equity. The culture of the service was poor, and this had resulted in low staff morale. Our assessment found there to be evidence of a closed culture in the service. The service did not have the processes in place to demonstrate it listened to and acted upon concerns, were open and responsive to suggestions, and used systems to drive improvement; all of which helped to ensure an open and transparent culture was in place.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. Staff and partners did not feel the service was well-led. Findings from our assessment supported this feedback. Records showed leaders were not always submitting statutory notifications without delay to CQC, and we were therefore not assured the manager, or the provider, understood their requirement to notify. There was an overall lack of documentation kept in responses to concerns, and where serious incidents had occurred there was no recorded investigation. Staff told us communication channels from managers and leaders was not always respectful or motivating and we received some examples of when management and leaders had not acted compassionately to people’s individual needs.

People did not feel they could speak up and that their voice would be heard. Staff did not have a whistleblowing procedure within easy access in the service and all staff told us they were not confident to speak up where there were issues or concerns. Staff did not feel supported to report any issues to the manager or provider. Feedback included, “I couldn’t raise any complaints or report things this would be unsafe for me, and I would lose my job.”

The provider did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had a diverse workforce in place, and staff had received their training in equality and diversity. Staff reported feeling intimidated by the provider and were scared. We heard examples of where staff’s well-being had not been fully considered and cared for. Some staff told us they felt pressured to work even when they were unwell, with 1 staff member giving us an example of how the provider had unrealistic expectations of them. There was a clear divide created by the management team in relation to how some staff felt they were viewed and treated. This meant staff did not feel valued and staff morale was low.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The governance systems in place had failed to ensure a consistently good service was delivered and had not identified the widespread shortfalls identified at this assessment. Many audits and governance systems were not in place meaning there was no clear monitoring or oversight of areas of risk such as with accident, incidents, falls, management of weights, behaviour monitoring charts, repositioning. Where audits were in place they were ineffective at identifying shortfalls in the service and therefore failed to drive any improvement. This was in relation to medicine management, care records and infection prevention. The provider’s own internal policies were not fully understood and therefore were not followed in relation to recruitment, new admissions and medicine management. All staff we spoke to as part of the assessment told us the quality of the management and governance needed improving.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. Whilst in practice the service worked in collaboration with other stakeholders, and had involvement of some other health professionals, they did not always make robust records around this. This meant it was difficult to audit and fully understand the care and treatment people had received, or when professionals made recommendations, and this placed people at risk of poor care. People and relatives told us the service did not always openly collaborate with them however, some feedback suggest a new messaging service has been well received by relatives, aiding in improving communication.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. The provider could not demonstrate they had a good understanding of how to make improvements happen or that they could use reflective practice to problem solve. As a result of this, lessons learnt were not evidenced and we saw many missed opportunities to learn from recent incidents and events.