Eastcotts Care Home with Nursing

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.

At our last assessment we rated this key question good. At this assessment the rating has changed to 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.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 and registered manager aspired to provide good quality care which was based on transparency and human rights. People told us that staff were kind and caring and we observed kind and attentive interactions. Professionals spoke about a caring and responsive culture at the service.

However, the culture did not focus sufficiently on improvement, and the governance and monitoring systems were not robust. This meant that people were not always provided with support that was person centred, and the providers vision, consistently embedded in day-to-day practice. Safety was not always given sufficient priority and risk mitigated. Staff were not always effectively deployed and there were gaps in the checks on fire safety systems and risk assessments.

Leaders had the experience and credibility to lead effectively. However, there was a lack of oversight in some areas and practice was not always consistently good. The provider systems were not always effective at identifying and addressing shortfalls. The shortfalls we identified in for example, health and safety and care planning had not been identified and addressed by the leadership team. Systems for identifying feedback from people and their relatives did not always ensure that issues were promptly resolved.

Responsibilities for action were not always clear, and some areas remained with the provider. There was a lack of a coherent overall plan for the service that all leaders were aware of. Following the inspection the provider sent us details of their plans for the refurbishment of areas of the home.

People and relatives knew who the registered manager was, and we saw that they were visible on the day of our inspection, speaking with staff by name and intervening appropriately. The registered manager was supported by a deputy manager and other nursing staff had delegated responsibilities for key areas including moving and handling and infection control.

Staff spoke positively about the support from the registered manager. Regular staff meetings were held to provide support and direction for staff.

Mechanisms for speaking up and seeking people and relatives’ views were not well developed.

We received inconsistent feedback from people and relatives about the care and the responsiveness of the manager and provider. Some people told us that they were very helpful and immediately addressed issues that arose, but others said that they had raised concerns, but they had not been investigated. Some concerns were raised during the inspection which the manager said they would investigate, but prior to this the last complaint was recorded as having been received in December 2023.

There was no record of a recent relative or resident meeting, and the manager told us that traditionally these had not been well attended but they told us that they intended to organise a meeting in the near future. The manager told us that there was a questionnaire which people could complete at the front desk and a suggestions box but there was no analysis available as there had been low take up.

In the entrance a, ‘You said we did’ poster was on display which said that people had asked for more activities, and this had been actioned.

Staff were aware of the whistle blowing process and confirmed they were able to raise concerns with nursing staff and or the registered manager and felt confident their voices would be heard.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff described an inclusive culture, where they were treated fairly. They told us that they were well supported at work by the registered manager and the provider and were able to raise any issues that arose. They told us they would recommend the care home as a good place to work.

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.

People told us about their experiences of living in the service, whilst some were good, concerns about care practice were also raised with us. For example, one person described being rushed by carers whose focus was on getting the task done. They did not feel that they had any control over their care.

We observed that staff were not always effectively deployed, and risks had not always been assessed effectively and mitigated. The shortfalls in practice which had not been identified by the leadership team.

The registered manager told us that the provider made regular visits to the home, and they also did a daily walk around but there was no record maintained of issues identified and addressed.

There were some audits undertaken including on infection control, medicines and dementia care. However, they were not always robust, and it was not clear what was reviewed. There were significant gaps in the audits completed, for example no audits had been completed on health and safety and care plans. The schedule for completing audits was not clear and we found that no night audit had been completed for a significant period despite issues having been identified when it was last undertaken.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for better outcomes for people.

Feedback from partner agencies was very positive. People and their relatives were also positive about how the service communicated with them and worked with other agencies. One relative told us, “Communication is good, they phone ……they do tell me things.”

The home benefited from having lots of visitors but there was no evidence of significant community involvement from local groups such as churches. Activities were provided.

The provider did not always focus on innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

Quality assurance was not well developed and there was no clear plan setting out actions needed. Learning was not always evident, for example they had not transferred learning from the shortfalls that had recently been highlighted with food safety systems to other areas such as health and safety.

There was some evidence of investment for example, the provided had recently introduced a new electronic recording system. Staff told us that this was working well.