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 Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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.

Professionals, staff, and relatives commented on the positive values of managers and staff. We found the values of the organisation were clear and put people at the centre of their support and care. The emphasis on promoting independence, choice and dignity were clear in all staff training and followed through in supervisions and practice support.

Systems and processes including meetings and staff supervisions promoted a listening culture and equality, and diversity were recognised and supported.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People benefited from the support of a manager and deputy manager who were visible in the service and modelled inclusive behaviours. Staff told us they were able to talk with the manager when they needed to. One staff member said the manager was, “supportive and hands on.” We saw the manager leading by example and saw friendly and familiar interactions between them and staff. Managers and staff were clear about their duty of candour, to be transparent and open when things go wrong.

The manager and provider understood their responsibilities in relation to their registration with CQC. The provider had applied to add a new service user band of ‘over 65’s’ to their registration and we discussed some of the risks around this. The manager and provider felt positive this new service user band would enable them to support a wider range of people but assured us they would complete robust assessments to ensure suitability with current people living at the service was considered.

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

Staff were proud of the service and said they felt able to raise anything with the provider and they would be listened to. There was a culture of openness which supported safe care and reduced the risk of concerns going unreported. Staff demonstrated understanding of safeguarding processes and were clear about their responsibilities to report concerns. The manager reinforced the importance of accurate reporting and escalation when needed, which supported a culture of transparency and accountability.

The provider had an easy read complaints procedure and communication and collaboration with relatives was frequent. The management team ensured everyone was treated fairly and were not discriminated against due to any protected characteristics.

There were processes in place to support staff to speak up, such as a whistle blowing policy and information containing contact details of the local authority and CQC. Staff confirmed they had access to the information.

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 commented on the positive values of the manager and provider.

Systems and processes including meetings and staff supervisions promoted a listening culture and equality, and diversity were recognised and supported.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Systems were in place to oversee care quality, including audits, incident reporting and action plans. Incidents were recorded and reviewed, with learning shared through staff meetings and handovers. Records showed lessons learned following incidents, with actions identified to reduce recurrence. Audits covered several topics as well as monitoring of peoples support needs.

The management team worked together to ensure there was oversight and effective governance at the service. There were computerised systems and processes to assess, monitor and improve the quality and safety of the service provided.

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.

People received ongoing support from various external health and social care professionals who represented them. Staff and leaders understood their responsibilities to work in partnerships with external care professionals to ensure people received joined up care. A professional told us, “I haven't had any issues with the Lodge, and the staff are always helpful and available.”

People were supported to access activities which mattered to them, such as social events and voluntary activities. This enabled people to remain connected to their community. We attended an outing where a person chose to go to the town centre and had a meal at a local pub of their choice with staff support. The person was supported by kind, trained staff who knew them well and gave positive feedback about the outing. Maintaining community links was important to people living at the service.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The manager described how lessons learned from audits were used to improve people’s care and support. They explained, “I perform “on the job training” as and when incidents occur, I observe a staff member attending a person and where necessary, ideally privately, inform the staff member how better to have dealt with the situation.” This demonstrated an ongoing commitment to reviewing practice and taking appropriate action to enhance the quality of support people received.

The provider told us the service had undergone a period of changes to support improvements and help ensure these were sustained over time. These included both improvements to the building and moving paper-based records onto electronic systems.