- Care home
Elpha Lodge Residential Care Home
Report from 6 August 2024 assessment
Contents
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
The provider had systems and processes to monitor and improve the quality of service provided. The medicines audits were to be reviewed in light of inspection feedback. Staff felt positive about the current registered manager. The registered manager promoted a positive culture and included them in changes within the service. This included being fully involved in the inspection of the service taking place. New systems were in place to record people’s care and support. These were still being embedded into the service. Staff were able to speak up if they needed to and were not concerned about raising issues with the management team. Partnership working was good, and the registered manager welcomed feedback to better support the home.
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.
There was a positive culture and shared direction within the service. Staff said the new management arrangements were good and lots of improvements were happening. Staff said they felt included and involved, and there was a good staff culture in the home. Staff said there is a “good staff teamwork and culture. Staff said the management team shared the same values with them to make a good place for people to live. One staff member commented, “I have worked here for years because I believe it has a very caring culture from the director downwards.”
Service literature, including staff policies and procedures, clearly set out the ambitions for the service and expected behaviours and culture of the staff team. The management team had an open-door policy to make staff feel comfortable voicing opinions and ideas.
Capable, compassionate and inclusive leaders
The management team had the skills, knowledge and experience to lead the service in a competent and compassionate way. Staff described the managers as “supportive” and “caring”. The current registered manager was a nurse by background and was dedicated to providing a good service. They told us they wanted staff to be fully involved in the service which would enable them to grow in their roles. The previous registered manager had worked at the service for many years and one staff member said, “There were teething problems when the management changed, but it has all settled down now.” Staff told us the registered manager and deputy manager were visible at the service and had been working with them to embed improvements.
Processes were in place to support a compassionate and inclusive style of leadership. The registered manager had worked with the local authority commissioning team to identify where improvements needed to be made and had worked with them and the staff team to implement improvements. Audit schedules and checks were in place to support the management team in monitoring the quality of the service. They also supported the development of staff, while including them in running the service.
Freedom to speak up
Staff told us they felt comfortable to speak up and found the registered manager approachable. Staff were confident that any concerns raised would be dealt with effectively by the management team.
The registered manager told us they had a ‘whistleblowing’ and safeguarding policy for staff to follow and that they discussed concerns in meetings. The registered manager had an open-door policy and people, relatives and staff were able to discuss any concerns they had.
Workforce equality, diversity and inclusion
The provider employed a diverse staff group with a range of age, gender and cultural backgrounds. Staff said they were clear about their roles and felt included and involved in making the home a comfortable and safe place for people to lead their lives.
Various policies and procedures were in place to support staff, including polices which dealt with bullying and harassment. The service was an inclusive workplace where staff were treated and supported as individuals. Staff told us they were able to ask for reasonable adjustments to be made to their working pattern for specific needs, for example to incorporate family emergencies.
Governance, management and sustainability
Staff had clear responsibilities and understood their roles, while still working as a team. The registered manager had a contingency plan in place to ensure the service continued safely if any type of emergency occurred, including fire or flood for example.
There were regular staff meetings to discuss people risks. Management were aware of their roles in quality, safety, and governance, and could articulate the governance structures in place. Processes were in place to help maintain a quality governance system, but they had not always identified issues arising, including those found during the inspection. The registered manager was going to review medicines and infection control procedures in particular to ensure they were more robust in spotting issues arising. The registered manager reviewed incidents within the home, including when people had falls. We saw incidents were reviewed and people’s care plans and risk assessments updated to reflect changes to their care needs. Notifications of accidents and incidents were sent to CQC in line with legal requirements.
Partnerships and communities
People described good collaboration between the care service and other health and social care services. People said they had confidence in the way staff worked in partnership with others to support the care service they received.
The registered manager informed us that they had good working relationships with external agencies, including community nurses, GP’s and the local authority commissioning teams. Staff told us how they worked with other healthcare partners and knew how to access support services within the community if people needed it.
Healthcare professionals visiting the service said they had a good working relationship with the staff and management team and the service engaged well with them. One healthcare professional said (after providing training into the service) , “Staff workshop was well attended and they participated well and were able to identify strategies that may work.”
Processes were in place to ensure partnership working continued. Referrals were made to external healthcare professionals, and this was monitored by the management team via audits and checks taking place. Handover, care records and diary records monitored contact or appointments with partners. Activity staff had a range of leisure interests taking place within the service and outside in the community. Staff were constantly looking for new ways to engage people within the local community. Pictures around the service showed a range of activities had taken place.
Learning, improvement and innovation
The management team supported learning, improvement and innovation. Staff had opportunities to learn from additional training and development opportunities within the service. The registered manager had recently completed IDDSI training with staff after an incident at the service. The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global standard to describe texture modified foods and thickened liquids used for individuals with dysphagia and who are at risk of choking. Staff confirmed there was a strong focus on improvement within the service. There was a focus on training to provide good outcomes and quality care to people. The registered manager was open to feedback during the inspection process and addressed concerns immediately.
Processes were in place to seek people, relatives’ and staff views on the service. This helped the provider to evaluate and improve the service they provided based on this feedback. The registered manager investigated safety incidents, such as falls and accidents, to identify causes and to ensure learning happened where needed to help improve and develop practice. A refurbishment programme was in place to continue to improve surrounding, particularly on one unit within the home. The registered manager told us improvements had been identified and were being completed. The service had changed to an electronic care record recording system and this was being fully embedded.