Elliscombe House

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• 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

During this assessment we found the service management and leadership was not always consistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. Systems of oversight of the service were in place, however these were not always effective and robust to assess, monitor and improve the quality of care people received. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There was positive feedback about the manager and deputy manager. Staff said they were open and approachable. The manager had set up various forums to make sure staff were included in decisions. The provider told us that had recently implemented “junior” meetings to ensure all staff were involved and able to provide feedback and input.

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our assessment there was not a registered manager in post. The home manager had been in post for around 3 months at the time of the assessment and told us they had plan to start the registration process with CQC. During the assessment we noted that the manager, was keen and passionate to develop the service and make improvements in the areas they had already identified. We noted the manager was working with the provider to implement systems and processes which would improve the quality of the monitoring to the service. However further time was needed for them to be able to appraise all areas of the service, implement systems and processes and assess the effectiveness of these.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Some staff commented on the lack of clinical leadership within the home. They felt this was a significant issue in a nursing home and needed to be resolved to improve people’s care. One staff member said, “A clinical lead is essential.” Comments about the provider were mixed. Staff felt they seemed to have “Very little experience or knowledge of care” and this could be an issue when trying to improve things in the home. Staff told us the current management team was good and they had improved things since starting at the home. One staff member said, “Management are involving staff in how we are doing things, which is good. Care is moving in the right direction, getting better.” Another staff member told us, “The new manager is good at getting the balance right to provide person centred care and always listens.”

The provider visited the service weekly and told us they meet with the management team, various department heads, care staff and nurses, however there was no recorded evidence of their involvement or support provided to the management team. The provider had contracted a consultant to review the service periodically. Through these visits, the consultant would highlight what needs to be done within the service. However, there was little evidence of these recommendations being incorporated in the service improvement plan or whether they had been completed. At the time of the assessment, the service did not have any clinical leadership. The service improvement plan had various actions identified, some of which were rated as “high” and dating back a significant amount of time. There was little evidence of a robust risk mitigation plan in relation to how the service was addressing these risks in the interim. The service had an audit schedule in place and actions were identified. However, it was not clear how these actions were monitored, allocated for completion, and prioritised. Audits were not always effective in identifying concerns and not all the concerns we found were identified by the service and if they were, there was little documented evidence of action planned to address them. We identified some incidents of unexplained injuries with no recorded evidence that the service had used these incidents to identify potential abuse and take action to prevent this in the future. This meant provider did not always operate effective systems to assess, monitor and improve the quality of care people received. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following our feedback, the provider and the manager communicate extensively with us about the actions they were going to take to address these shortfalls and provided assurances that swift action would be taken.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.