Eastern 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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant governance systems were not always effective in identifying and addressing concerns.

The service was in breach of the regulation relating to good governance, mainly due to ineffective auditing systems, risk management and record keeping.

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.

The provider had a shared vision, strategy, and culture based on transparency, equity, equality, human rights, diversity and inclusion, engagement, and an understanding of people’s needs and the challenges they faced.

The care and support provided to people reflected CQC’s Right support, right care, right culture guidance. People were listened to, and their rights were respected. They received compassionate care and were supported to live as independently as possible. Staff understood their roles and responsibilities in delivering person-centred care.

Overall, people and relatives spoke positively about the care and support they received, reflecting the open and inclusive culture of the service. A person told us they were “very very happy” at the service. Another person said they “really like it” there and “get a lot of support”. A relative spoke very positively about the service, describing it as caring, respectful, and well-managed, with good communication and clear improvements in the person’s wellbeing. They also said they would recommend the service to others. A staff member described the service as the “best place to work”

Leaders were visible and supportive. They made themselves available to people, relatives and staff. The service was overseen by an experienced registered manager and care manager. Together, they provided effective leadership and ensured staff received appropriate support. A person using the service commented, “[Registered manager] is really good; always at the end of the phone.” A relative told us, “The manager is welcoming” and explained that they were able to contact them at any time.

Staff understood their roles and responsibilities and spoke favourably about the support and guidance they received from their manager, as well as the tasks delegated to them. A staff member told us, “Management is absolutely fine.”

Throughout the assessment process, the registered manager and care manager engaged collaboratively and were receptive to our feedback.

Staff felt comfortable to raise concerns and provide feedback, contributing to a culture of openness and transparency.

Staff understood their responsibility to report concerns internally and externally to other organisations if needed. They felt comfortable engaging with leaders and voicing their opinions. A staff member told us they would speak to their manager if any issues arose.

The provider promoted equality and inclusion among staff and people using the service.

The service had an ongoing improvement plan covering staff wellbeing and workforce stability. Priorities included promoting staff wellbeing through open communication and identifying support needs, as well as recognising potential candidates for progression to senior roles. Staff told us they were treated fairly, felt supported and valued.

Governance systems were not consistently effective in ensuring safe, high-quality care.We found concerns in record keeping, audits, policies and delegated healthcare activities (clinical tasks assigned to care workers by a qualified healthcare professional), which meant we were not assured governance consistently supported safe and effective practice.

Some care records were overly detailed, repetitive, or contained conflicting or inconsistent information. For example, 1 person’s behaviour support plan contained mixed and unclear behavioural guidance, making it difficult for staff to follow in a crisis. Another person’s mental health plan included unrelated information, and mental capacity assessments were not decision-specific, and had unclear outcomes. Conflicting DNACPR preferences were also recorded. These issues could make it harder for staff to locate relevant guidance and increase the risk of inconsistent practice.

Audit and governance systems did not consistently provide assurance that issues and areas for improvement were being effectively identified and addressed across the service. Existing quality assurance systems had not identified issues found during the assessment, including medicines management concerns and inconsistencies in care records and documentation.

Organisation policies were not always accurate or up to date, referencing other locations or named managers, which could confuse staff.

Delegated healthcare activities, such as medicines administered via PEG, lacked adequate oversight, and we found limited assurances regarding the effectiveness of staff competency assessments for this activity. For people receiving the regulated activity of personal care, their medicines were stored centrally in onsite offices. While this practice did not support people’s independence, the provider told us it was for safety reasons; however, these decisions were not clearly recorded or regularly reviewed.

Overall, these concerns demonstrated weaknesses in governance systems. The provider could not demonstrate that systems were consistently effective in identifying and addressing issues, maintaining accurate and up-to-date records, or supporting safe and consistent care delivery. Following the assessment, the provider had begun making improvements. Aspects of governance systems that worked well included an open and inclusive culture, visible and supportive leadership, person-centred organisational culture, and a continuous improvement approach.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. We saw evidence of partnership working, including clear records of engagement with health and social care professionals, indicating a coordinated approach to meeting people’s needs and improving the quality of care

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They actively sought feedback from people, relatives, staff and professionals, which they used to develop and improve the service.

The service maintained a live improvement plan, outlining key priorities to develop staff, strengthen quality assurance, and improve people’s outcomes. The plan was informed by feedback from people, relatives, and staff, as well as incident analysis, risk trends, and management reviews, ensuring learning and improvements were embedded across the service. In addition, the provider demonstrated a proactive approach to learning and improvement after we provided feedback on the assessment. They had started implementing changes to address some of the concerns identified.