- Care home
The Elms
Report from 1 May 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
In the weeks prior to this assessment visit, a significant number of concerns were raised by the police and Integrated Care Board about the number of serious incidents occurring in the service. This included a high number of incidents where police were called and where children and young people presented at hospital requiring treatment for self-harm injuries. The provider failed to take these concerns seriously, and despite meeting with the police, the number of incidents remained high and children and young people continued to be placed at risk. Instead of recognising there was a problem and taking action to rectify it, the director instead stated that the concerns came from a lack of understanding about the service type. This meant they failed to take any action to protect children and young people from harm. Following our assessment visit, we requested information to assure us that the provider would take action with regard to our serious concerns. Instead, the providers response included long timescales. For example, a meeting with staff over a month later. This meant we were not assured the provider would take prompt action in response to concerns and protect children and young people from harm.
This service scored 4 (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.
Capable, compassionate and inclusive leaders
Leaders did not demonstrate concern for the serious nature of the incidents occurring in the service, nor their frequency. The director and provider demonstrated to us they did not take these seriously, by stating that other organisations raising concerns were only doing so because they did not understand the service type and not because there was legitimate reason for concern. Instead of taking action to protect people from harm, they instead suggested CQC come and inspect as they felt there were no issues. This did not match our findings during the assessment visit. After the assessment visit, they displayed further lack of understanding of the seriousness of our concerns. For example, we asked them for information on how they could assure us people were going to be safeguarded from avoidable harm. They provided an action plan which included long timescales, such as having meetings with staff in over a months time.
There were insufficient processes in place to monitor the quality and safety of the service and to act on concerns. This meant that the provider had been unable to identify the serious concerns we found during our assessment visit and act on these. The providers inaction meant people were placed at the risk of avoidable harm, and some people did come to harm that may have been preventable.
Freedom to speak up
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.
Workforce equality, diversity and inclusion
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.
Governance, management and sustainability
The processes in place did not ensure that people received good quality, sustainable care, treatment and support. They provider failed to act on information about risk and put in place steps to protect people from harm. For example, where incidents occurred, appropriate actions were not implemented to reduce the risk of recurrence.
Partnerships and communities
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.
Learning, improvement and innovation
The provider did not continuously learn and improve. Despite concerns being raised with them by the police and Integrated Care Boards about incidents happening in the service, they chose not to take action to implement changes that protected people from the risk of avoidable harm. The provider showed a disregard for concerns raised, and demonstrated this by admitting a person to the service after they had had their registration removed. This person had risks similar to those who had previously lived at The Elms, and that staff had been unable to safely manage. This demonstrated a disregard for people's safety and welfare.