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 the same.

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 previously in breach of legal regulations in relation to good governance. The service remained in breach of this legal regulation.

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.

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. We spoke with the registered manager during our assessment and identified concerns that should have been shared with the Care Quality Commission (CQC). These were subsequently provided.

People told us they were happy with the care provided and communication with the senior care staff. They were aware of who the registered manager was. A person we spoke with said, “[The manager] chats to me on occasions. Every 1 or 2 weeks. She makes sure everything is ok.” 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 was not.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills or knowledge to lead effectively.

While the registered manager was experienced, they occasionally overlooked regulatory reporting requirements for the CQC. Additionally, their oversight regarding safeguarding and Mental Capacity Act (MCA) principles lacked the necessary consistency and rigour.

We identified improved audit systems in place which included peer review from another registered manager. However, whilst audits identified where improvements or actions were required there was no documentation to prove any action had been taken. For example, a ripped mattress and a broken emergency light. We spoke with the registered manager regarding these actions and were assured they were in progress. This meant the audit process and required actions were not fully embedded into practice. Reporting to CQC was not always actioned in a timely manner.

Staff were supported by leaders and we saw there were safe recruitment processes in place.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

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. Staff were able to tell us what whistleblowing meant and how they could report concerns. The service had an updated policy in place. The policy provided guidance for staff about whistleblowing both within and outside of the organisation.

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 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.

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.

Systems to audit the quality and safety of the service had improved since our last assessment. However, improvements were required to embed the process and evidence how and when areas for improvement had been actioned.

During this assessment fire safety concerns were identified related to outdated risk assessments, fire safety checks and the contents of the evacuation grab bag used to support people during and after an evacuation. The checks had been missed as the service only had 1 trained fire warden. When a planned absence took place oversight of these tasks was missed. We raised these concerns immediately with the registered manager. We were provided with an update and assurances that actions had taken place within 24 hours.

The provider mostly understood 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 staff team engaged with the local communities and partners. This included GP’s, nurses and others involved in providing care and support to residents. There was an activities programme in place. A Person we spoke with told us, “Yesterday we did bingo. We do knitting. This afternoon someone is coming in to do exercise. Last Tuesday Elvis was in. He’s been about four times. There’s an artist coming on Thursday.” This meant the service promoted a sense of community.

Care staff we spoke with told us they were sometimes involved in developing people’s care plans with them. Senior staff usually completed care plans, 2 residents spoke of being involved with planning their care. However, this did not appear to happen consistently, and further work was required to embed this practice to support person centred care.

The provider did not always focus on continuous learning, innovation and improvement across the organisation. 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.

The provider had new systems and process in place to share lessons learnt. We saw evidence of staff meeting minutes which identified information being shared with all staff. The registered manager had begun to conduct analysis of accidents or incidents to prevent issues reoccurring. However, these still required embedding into everyday practice. There were still concerns during this assessment that required increased oversight to reduce risk to service users. This was a missed opportunity to reduce risks and improve the safety and quality of care.