Eaton Lodge Nursing Home

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-centered 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 did not always support the delivery of high-quality, person-centered care.

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

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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There was a positive culture at the service. Staff worked well together, and this reflected on how well they treated people and their visitors. The registered manager was supported by a deputy manager. The deputy manager worked along side staff which enabled them to keep an overview of staff practice and provide staff with support where needed. The provider also spent time at the service and knew staff and people. There were regular meetings with staff to share information. Staff were positive about communication at the service which was supported with handovers when shifts changed. Staff told us, “Every morning we have a handover. The nurse explains everything, new residents, diets, health issues, it is very helpful and informative.”

Whilst leaders understood the context in which the provider delivered care, treatment and support there were areas where improvement was needed. Leaders did embody the culture and values of their workforce and organisation and did so with integrity, openness and honesty.

The registered manager was supported by a deputy manager. Both managers were keen to provide a well led service.

The provider and managers were responsive to the concerns we raised during the inspection and action was taken to improve the safety of the service in response to the issues we identified.

The registered manager and provider understood their responsibilities if a duty of candour incident occurred. A duty of candour incident is where an unintended or unexpected incident occurs which resulted in the death of a service user, severe or moderate physical harm or prolonged psychological harm. When there is a duty of candour event the provider must act in an open and transparent way and apologise for the incident.

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

People, their relatives and staff were all free to speak up if they had any worries or concerns. Staff were able to raise concerns directly to the provider if they needed to and knew who to contact if they needed to whistleblow to an external organisation. One staff told us, “The manager is good I can go and speak to her anytime if I am worried or have a suggestion. She is very nice; the deputy is really nice too. They listen and are good to us. I have no concerns or worries about the service. I think all is going well.”

Relatives and people were positive about the management of the service. One person told us they would feel comfortable raising any concerns but had not had to. They said they were always encouraged by the deputy manager to speak about any worries.

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 told us they felt respected and valued by the provider and service managers who was supportive. Staff told us they were supported to have time off for religious holidays as much as possible. The service celebrated important events from across various cultures and religions to ensure staff felt welcome.

The provider did not have 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

Auditing and checks on quality needed to be improved to ensure issues were identified and addressed. We identified a number of concerns during the inspection which should have been identified and addressed by the providers quality assurance systems. For example, where staff were crushing a medicine which should not have been crushed.

Care plan auditing also needed to be improved as it should have identified gaps in care planning and addressed these. For example, one person was at risk from aspiration and there was no risk assessment in place for this, although staff did know how to support the person. This was put in place immediately after the inspection.

We identified a number of environmental concerns such as oxygen bottles not being secured correctly. These concerns had not been picked up and addressed by quality assurance systems.

There was an electronic care planning system in place to record the support people were being provided. However, it was not being used effectively to identify where there were gaps in people’s support or areas where action was needed. For example, regarding constipation or people’s fluid intake.

The last CQC inspection rating was on display as required. Incidents and accidents were reported to CQC when appropriate and in line with legal regulations.

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.

Feedback from partners was positive. Partners told us people were referred to them for further support appropriately and staff followed referral protocols well. Partners told us they had no concerns about how the service and managers worked with them in partnership. One partner told us how they felt the service was well managed.

People were referred to health and social care professionals to support their care. For example, people were referred to specialists where they had issues with swallowing. The service also worked with local paramedics to reduce the need for people going to hospital where care could be provided to them in the home.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. However, there were still areas where improvement continued to be needed and embedded.

The registered manager managed two services. It was clear at this inspection lessons had been learnt after we’d found concerns at the other location. There were systems in place to provide support to people. For example, there were protocols in place for people where they had diabetes and there was a system in place to support rotating pain patches. However, there was still work to do to ensure these systems were working effectively and people’s care and support was fully safely managed.