Earls Lodge 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 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 71 (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 equity, equality, and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.People told us staff were kind and caring, and we observed people to be treated with respect and kindness. Relatives also spoke positively about the team. One relative said, “They are very nice, I don’t have any problems here. You only have to tell them, if you have a problem, they will get it sorted.” There were display boards around the building advising staff, people and relatives of different topics such as hydration and nutrition, allergy awareness, safeguarding and antibiotics.

The provider had 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. The service was managed and run by leaders who were visible and approachable. One person told us, “I can speak to [a manager], their door is always open, and I have had meetings with them. The Seniors are all easy to talk to.” As well as managers working at the service, the regional manager also visited the service often and shared feedback of their visits with the team. The managers had meeting with seniors to address any issues collaboratively. The registered manager understood their regulatory requirements in line with their registration. They had notified CQC of incidents in line with the requirements of their registration.

The service fostered a culture where people felt they could speak up and their voice would be heard. Relative meetings were arranged but not many relatives attended. Even though relatives did report if they wanted to speak to a manager, they would be able to do so, but many relative told us they had not been asked for feedback. Staff surveys were completed by the provider; we reviewed a sample of the last survey where feedback was overall positive. Staff told us they would be able to speak up if they needed and share feedback. One staff member said, “If you are at work, you can make suggestions. You can tell the manager anything.”

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. The provider demonstrated a commitment to equality, diversity and inclusion within the workforce. There was a diverse workforce, with staff from a range of minority ethnic backgrounds.Staff records showed staff had completed training in equality and diversity and staff told us the team worked well together. Leaders promoted an open and inclusive culture where staff felt able to contribute regardless of their background, characteristics or role.The provider had up to date polices which reflected current legislation.

The provider’s governance systems were not always effective in identifying gaps in the service. The quality of the service provided was regularly monitored and assessed. Checks and audits completed includedmedicines, Infection prevention control, oral hygiene, pressure sore, care plan review, moving and handling spot checks. However, we found concerns which included gaps in people’s care records, gaps in recording of fluid and food intake, medicines and the environment. We discussed this with the registered manager, and they acted on these issues immediately.

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. We reviewed minutes of meetings with district nurses where people’s progress was discussed. Actions were set and follow ups were completed. We received no concerns in relation to working in partnership with other professionals. There was lots of community fundraising and specific work for Veterans being completed at the service, some of which had been reported in the local newspaper. The management team was open and welcomed feedback on any areas for improvement.

The provider focused on continuous learning, innovation and improvement across the system. Identifying and implementing ways to improve was inconsistent. Where the provider had found discrepancies, meetings were held with seniors to address the concerns and implement changes or learning. The provider was proactive about the feedback we gave during the assessment and started to act on the any issues we had found promptly.