Eastwood House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained the same.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was previously in breach of legal regulation in relation to safe care and treatment and good governance. The service remained in breach of legal regulation in relation to safe care and treatment and good governance.

This service scored 56 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff mostly listened to concerns about safety and mostly investigated and reported safety events internally. Lessons were starting to be shared to continually identify and embed good practice.

The provider had taken action to improve the recording of incidents and accidents within the care home. These were reviewed and analysed in a timely manner. Lessons were being shared with staff during meetings to improve practice. We saw investigations of incidents and risk reviews.

This meant that steps had been taken to improve the safety of residents.

However, the registered manager was still uncertain regarding what information should be reported to the Care Quality Commission.

This meant that whilst improvements had been made, they were still in the process of embedding change.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider mostly worked well with people and healthcare partners to establish and maintain safe systems of care. They mostly managed and monitored people’s safety. We observed staff contacting relatives to ensure continuity of care, for person’s potential hospital admission. Staff assessed people’s needs prior to moving into Eastwood House. Care plans had been updated to include people’s medical conditions for example people living with diabetes. This meant staff had guidance in how to support the person with their diabetes and recognise if there were changes in their condition. However, fire safety checks had recently been omitted in error. The registered manager actioned these omissions when they were identified by CQC.

Staff we spoke with were able to describe how they de-escalated service users who became distressed. However, guidance within care plans did not contain the level of detail to support staff who may not know the person well to ensure they received consistent safe care. The terminology used in care plans was not always person centre or reflective of actual events

People told us they felt safe living at the service and staff supported them to seek advice and support from other healthcare professionals when needed. We found senior care staff referred to external professionals and discussed advice during handovers. This meant care staff were aware of advice provided.

The provider mostly worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They mostly concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The Registered Manager demonstrated some oversight of safeguarding and mostly worked within the principles of the MCA

Safeguarding processes in place had been strengthened to ensure people were protected from the risk of harm. We found staff received safeguarding training; they could explain what safeguarding meant and staff reported incidents to the registered manager. These were reviewed and actions taken when required. However, further embedding of reporting to the local authority or CQC was still required. This meant there was still a risk an incident could re-occur.

Staff were aware of who had lawful restrictions in place and who did not. This ensured people were restricted lawfully.

All people and their relatives told us they felt safe living at Eastwood House, a service user we spoke with said, “I feel safe -very safe”, Another service user we spoke with said “I feel safe. They come and check at night every two hours.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider and registered manager ensured staff supported people safely. We found staff had improved guidance in place to ensure people were supported in a safe way and according to their needs. For example, pressure area care had improved to reduce the risk of harm to service users. We found people were repositioned in line with their assessed needs to reduce risk of skin damage. This meant staff had accurate information to support them safely.

We spoke with 2 people who told us they had been involved in the care planning process, including regular medical reviews. This meant people were more likely to receive care aligned with their needs or wishes.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Whilst improvements had been made to risk assessments regarding stairs and falls risks. There were concerns related to fire safety and personal emergency evacuation plans (PEEPs), we found they identified one service user as requiring the use of a stretcher to evacuate the building. However, the service did not have a stretcher. The fire safety action plan was out of date and fire checks had not been completed over the previous 2 weeks. This placed people at an increased risk of harm. We fed this back to the provider who took action to address the issues raised.

Checks to the environment were carried out to ensure the building was safe. For example, the provider ensured inspections of heating systems were carried out by qualified professionals yearly. However, during our assessment radiators and some water outlets were reaching temperatures above the recommended readings. The registered manager addressed these concerns, and the service was due a yearly full heating system review.

We observed the upstairs bathroom was signposted as a toilet. However, the room was full of stored equipment and would have been a risk to service users had they attempted to access the toilet. We raised this with the registered manager. We were told that a plan was in place to re purpose this room. However, this had also been noted at the local authority review October 2025.

Wardrobes and other heavy furniture were secured to walls, this prevented furniture from tipping and falling on people and staff. We found the building to be secure which prevented people at risk of leaving the building alone from harm. People told us they felt safe in their environment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were kind and caring, people we spoke with told us there were enough staff on duty. A person we spoke with told us, “They are very nice. They all look after you very well. They are always here. Sometimes they are busy, you might have to wait a few minutes. But 1-1 they look after you very well.”

Records showed staff received training and people felt staff were skilled, Recruitment processes were followed to ensure only suitable staff were appointed. Checks including, interviews, references and Disclosure and Barring Service (DBS) checks were conducted before staff started working at the service. DBS checks provide information about convictions and cautions held on the Police National Computer. The information helped employers make safer recruitment decisions. Staff approached and supported people with kindness.

The provider did not always assess or manage the risk of infection. However, they did detect and control the risk of it spreading and share concerns with appropriate agencies promptly.

Infection and prevention control measures in place were not always effective. The home appeared clean and generally tidy. Residents’ rooms, however, did contain large amounts of either medical equipment or continence products. We raised this with the registered manager who was in the process of providing improved storage space for this type of equipment. We also observed furniture to be mostly clean, however there were many areas of damage to the woodwork, surfaces and floors. For example, skirting boards, radiator covers and stair rails. Which meant it could not be cleaned effectively. There were maintenance plans in place however, they had not addressed these concerns. These concerns were also raised by the local authority at an IPC audit in October 2025.

Shared equipment used to aid people’s mobility was unclean with visible debris. An effective method of cleaning had not yet been found. Infection prevention and control processes were improved since our last assessment. However, we did identify 2 duvet covers stained with bodily fluids, 2 crashmats that were damaged and unclean and 1 ripped mattress. Audits had identified the mattress needed replacing however there was nothing recorded regarding replacement. We spoke with the registered manager regarding this and received assurance this was to be replaced. The crash mats were also disposed of and replaced. This meant people were at risk of contracting infection through unsafe infection prevention and control practices. People and their relatives raised no concerns regarding the cleanliness of the home.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The provider did not always ensure medicines were managed safely. We found issues with storage,securityand record‑keeping whichplaced people at risk of avoidable harm. The medicines fridge had been above the safe temperature range on multiple occasions withno documentedaction andwas later found switched off. This meant the providercould not be assuredthat temperature‑sensitive medicines remained safe to use.

Medicines were not consistently stored securely. We found the clinic room and cupboardsunlocked andexpired or short‑dated medicines still in use, which increased the risk that people could receive medicines that were no longer safe or effective.

Records weregenerally completed, butperson‑centred information was limited, and as required medicines (PRN), did not consistently guide safe decision‑making. Staff also signed Medication Administration Record (MAR) charts for insulin that had been administered by external professionals, resulting ininaccurate records.

There were some examples of good practice, including safe management of topical medicines and thickeners, and staff had receivedmedicinestraining.

However, audits had not yet resulted insustained improvement, and governance systems did not alwaysidentifyor address the concerns we found.These shortfalls meant the providerdid not have effective systems in placeto ensure medicines were stored,recordedand administered safely.