Eastwood House

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 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.

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

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Systems and processes in place required strengthening to ensure there was an open and honest culture. We found some incidents which had not been reported by the registered manager to the local authority or CQC. This included where a person had become injured. Whilst people and their relatives told us they were happy with the care provided and communication with the senior care staff. Not all the relatives we spoke with were aware of who the registered manager was. A person we spoke with said, “I would raise any concerns with the care home directly, the senior care staff, not sure who I would speak to if I didn’t get a reaction from them.” Relatives we spoke with told us they had not been invited to a relative’s meeting in 2025. This was a missed opportunity to involve people and their relatives in shaping the service. Staff meetings were held and their feedback acted upon. Staff spoke positively about the senior leadership team and told us they were approachable and kind. Staff received supervisions to discuss what was working well and what wasn’t.

The registered manager was experienced however they were not always aware of their regulatory requirements. We found they lacked knowledge on what needed reporting to CQC. There was poor management oversight at the service. For example, we asked on a number of occasions which people were subject to a Deprivation of Liberty Safeguard (DoLs). This is where a person cannot make decisions about their care and treatment so restrictive care arrangements are legally authorised in a person’s best interest. The registered manager was unable to tell us who had a DoLs in place and who did not.

We found external organisations such as the local authority and medicines optimisation team identified areas for improvement rather than the provider’s internal processes. For example, the local authority found issues with care plans which had not been identified internally. We found the registered manager and senior care staff completed audits of the service, but these were not reviewed by the provider. This meant there was no oversight of the registered manager’s performance. Staff told us, they were confident in the registered managers and senior care staffs leadership skills.

Staff told us the management team were approachable and encouraged them to speak up. We found staff were supported in supervisions and meetings to share concerns and ideas in their preferred environment. Whilst staff were able to tell us what whistleblowing meant and how they could report concerns, the policy in place was not accurate. The policy did not include details of the CQC and referred to the local authority as the regulator. The policy did not provide sufficient guidance for staff in regard to whistleblowing outside of the organisation. This increased the risk of staff not reporting concerns to CQC and the local authority.

Staff were supported by training and an equality and diversity policy. Staff told us, they felt valued in their roles and the management team supported them both personally and professionally. Staff told us they felt they were treated fairly and kindly by the management team.

Systems to audit the quality and safety of the service were not effective in identifying and addressing areas for improvement. Whilst some audits were undertaken, these were not always accurately completed, and they were ineffective in identifying areas for improvement. For example, a medicines audit completed in August 2025 failed to identify any of the issues we identified. The audit for cushions was not completed and was entirely blank. The infection control audit was completed bi-monthly, therefore issues relating to infection control had not been identified in a timely manner.

There was not a process in place to monitor DoLS or document any conditions. This meant there was poor oversight and increased the risk of people having restrictions imposed upon them unlawfully. Audits to monitor people’s care records were not in place therefore none of the issues we found were identified or acted upon. There was a lack of systems and processes in place which meant people were at risk of receiving poor care not aligned with their needs.

The provider was reactive to our feedback and sent an action plan addressing the most serious concerns.

The provider did not always understand their duty to collaborate and work in partnership with others. As detailed within this report, people and their relatives told us they were not involved in reviewing or planning their care needs. Care staff we spoke with told us they were not involved in developing people’s care plans with them. A staff member said, “I’m not really sure about the care plans I know the seniors do them, but I don't know how often they are reviewed.”

People and their relatives told us staff supported them to access services outside of the organisation such as the hairdresser and chiropodist. People, their relatives and staff told us events were held such as a summer BBQ and a Christmas party, they also explained children from the local area visited people living at the service. This meant the service promoted a sense of community.

The provider did not have systems and process in place to share lessons learnt. The registered manager did not conduct detailed analysis of accidents or incidents to prevent issues reoccurring. Staff meeting minutes we reviewed did not detail any accidents or incidents, there was no discussion of what learning took place following incidents. Known issues as detailed within this report were not acted upon. This was a missed opportunity to reduce risks and improve the safety and quality of care.