Eden Lodge Residential Care 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-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 changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 29 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Systems were not used effectively to ensure people; their relatives and staff were listened to. The feedback we received told us that actions were not followed up and feedback from meetings was not shared.

Leaders did not create a shared culture of effective care, meaning there was a poor-quality culture at the service. Staff were not aware of any shared visions or strategies to help people receive good quality care.

We found gaps in documentation and audits which meant that a clear direction of change and improvement within the service was not identified which placed people at risk of unsafe care and treatment.

The provider was in a process of management change at the time of the assessment.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge or experience to lead effectively, and they did not do so with integrity, openness and honesty.

Feedback from staff at the time of the assessment spoke negatively about their experiences under previous management.

The provider failed to maintain oversight of the quality of care being provided and failed to monitor the performance of the service and previous management to ensure the service was safe and well-led.

The provider was present during the site visits and, overall, was receptive to our feedback and took some steps to immediately improve safety in the service.

People did not feel they could speak up and that their voice would be heard.

Leaders did not actively encourage an open and transparent culture. Staff described feeling unsupported when raising concerns and lacked confidence that issues would be acted upon. There was limited evidence of challenge, reflection or constructive feedback used to improve the service. This created a culture where poor practice could persist without appropriate processes and systems.

Staff told us of instances they had raised issues and were later told that they should not have said anything. This did not support a culture where staff felt open to speak up and raise concerns.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff did not always feel supported or empowered and felt that the morale was low at times.

Whilst some staff felt they were treated equally, others felt the management team had favourites within the staff team. Whilst policies were in place, leaders failed to evaluate how staff felt and were not aware of the poor quality of care provision.

However, staff told us they support each other in their roles which they appreciated.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service was not well-led. The registered manager had recently left the service. Senior staff acted up into the role to carry out management tasks but were expected to complete these in addition to undertaking caring duties. This compromised their ability to effectively lead the home as was required.

The systems and processes to monitor quality and safety were not effective in protecting people from the potential risk of harm. The provider had not identified the shortfalls in the expected care standards. For example, their audits had not identified the concerns found at this assessment around the environment, infection control, medicines, person centred care, care plans and staffing.

These shortfalls had not been identified or acted upon in a timely manner. Failure to maintain oversight of quality monitoring processes placed people at risk of receiving poor care and the risk of harm.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

The provider did not consistently share important information with external agencies, including making safeguarding referrals when required.

The provider had recommendations of improvement from the Fire Service following their visit to the service at the beginning of the year. Although the provider had taken some action to remedy the concerns, some areas still needed addressing.

Advice and guidance from healthcare professionals had not always been completed, for example monitoring diabetes which placed people at risk of harm.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

At the time of assessment, we found multiple areas of concern in the service that had either not been identified or addressed.

There were no effective systems in place to enable the service to learn from incidents, accidents, near misses or safeguarding concerns.

Audits were not effective in identifying where improvements needed to be made and the service was not meeting the fundamental standards we expect from care services. Although the provider took action to make improvements in response to our feedback following this assessment, we cannot be assured these improvements will be sustained and embedded.

Where concerns had been identified through audits, appropriate and timely action had not always been taken. This meant improvements were not embedded in practice, placing people at risk of receiving care that did not consistently meet expected standards.