Earlfield Lodge

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. The provider was previously in breach of the legal regulation relating to good governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The provider had its aims of the service described in the statement of purpose and service user guide. The service had worked on making improvements to the culture of the service which were acknowledged. This included involving and developing staff more. Leaders now needed to ensure the vision, values and strategy was known and understood and developed through a structured planning process in collaboration with people who use the service, staff and external partners.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. There was a staffing structure in place with roles and responsibilities. The provider was aware this structure required regular reviewed as the service developed further.

People spoke positively about the registered manager being approachable and supportive. People and staff commented that the service had improved. A person said, “Since [Name of registered manager] has been here things have improved a lot.” Another person said, “‘It’s improved 100 per cent without a doubt. It is down to this particular manager.” A staff member said, “The registered manager has made lots of positive improvements.”

The office had been relocated to the ground floor by the entrance to the service. This had supported better management oversight of the service and improved visibility of senior and administrative staff to visitors and professionals. A staff member said, “The office relocation has been positive.” A health and social care professional said the home was, “Calm and welcoming.” We received some feedback that leaders could be more visible around the service, interacting with the whole staff team. This was acknowledged by the provider.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Systems were in place for staff to speak up including supervisions, staff meetings and surveys. Staff told us they were able to raise concerns and issues. A staff member said, “Staff speak a lot in staff meetings.” A staff member said, “The staff team work well together, people support each other.”

The provider valued diversity in their workforce. They were working towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff had access to equality training to support their understanding of protected characteristics and awareness of bullying and harassment. Staff were treated with equity and fairness. The service had worked on building a team approach, continued to ensure this is united. The provider had an equality and diversity policy. We highlighted where data collected in relation to equality and diversity could be utilised better to demonstrate how this policy was put into practice. For example, data collected in the recruitment process and awareness days.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had complied with the enforced conditions imposed at our last assessment. The provider had sent regular reports to CQC which demonstrated improvements made at the service. The service had made improvements to governance systems to ensure previous breaches in regulation had been met. Audits systems were being reviewed and refined to ensure they met the service’s needs. For example, some further development of recruitment, medicine, safeguarding and care plan audits would support the service in accuracy of information. For example, 1 recruitment file was not accurate for the location and staff Disclosure Barring and Service checks were not renewed. The service had an action plan which was being progressed to ensure the continued development of the service. Analysis of response times to call bells was not currently possible, this was included in the service action plan. Notifications had been submitted to the Care Quality Commission (CQC). We found 1 safeguarding notification which had not been submitted, which the provider said they would complete retrospectively. At our last assessment we found some of the provider’s paperwork was under a different company name not registered with CQC or a different CQC location. Whilst this had improved at this assessment, this was still evident in some documentation and staff recruitment files. The registered manager worked to address this during our assessment.

The provider’s CQC assessment rating was displayed at the service and on the provider’s website as required. Staff received training in confidentiality. During the assessment information required to support people in an emergency which contained confidential information was secured. The office had been relocated to a position which enabled improved management oversight of the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. The service was working towards strengthening and community links and partnerships to ensure the service continued to develop and provide positive outcomes for people. This included developing links with religious partners to meet peoples religious and cultural needs and enhancing access to the local community for people. People told us, “I would like to get back into the community,” and ‘I am assuming I can go outside, I don’t walk at the moment, so I don’t get out.”

The service had developed positive relationships with health partners and were benefiting from additional training on offer to develop staff skills and knowledge.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The service had made numerous improvements in the environment, person centred care and governance of the service. A staff member said, “The home has improved. It is going in a good direction; it is going well.” Safe systems of work were being embedded. The service had an action plan which identified areas planned for development which would continue to improve outcomes for people. Staff told us learning was shared. For example, through team meetings and staff communications. Further development was required when incidents and concerns arose to ensure learning mitigated future risk effectively.