Eskdale House Supported Living Service

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 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 in breach of legal regulation in relation to good governance. The systems to assess and manage the quality and safety of the service were not always effective.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service was in the process of instilling a shared vision, strategy and culture for the service. However, further improvements were required to ensure this was fully implemented. The registered manager told us, “Since we took over the service, we have been firefighting to improve people’s care and safety. One of our main objectives is to have a full complement of effective staff with the values needed and a good work ethic.”

Managers and leaders led by example and monitored practice against the service’s values. One staff member told us, “We are trying to mould the permanent staff and when new staff come in, we will be able to teach them [how we want care to be delivered].”

The service was working towards ensuring each individual person was at the centre of their support.

The service had inclusive leaders 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. The registered manager told us, “The [operations manager] has a good background in the learning disability and autism sector. I am supported well by them, and they know my strengths and where to help.”

However, over the course of the inspection, we found further support was required at provider level to ensure governance of the service was effective.

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

The service had a whistleblowing policy which staff understood. Staff felt able to report concerns in one-to-one meetings and the registered manager had an open-door policy. I have read the whistleblowing policy and, since [Westmorland and Furness Council] took over, we have talked about it in face-to-face training. I feel confident to whistle-blow.” Another staff member told us, “I have access to the whistleblowing policy, and I know how to raise issues. I feel empowered to bring things up.”

We discussed with the registered manager the need to formally collect feedback from people and staff about the quality of care delivered to ensure they could use this to act on issues and improve practice.

The service 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 felt they were treated equitably and had an inclusive culture. One staff member told us, “It's great working here and with the managers. It's a fair culture and everything is equal.” Another staff member told us, “The [staff team] is made up of people from different cultures and we are respectful of each other.”

The service 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 provider’s processes had not identified the issues we found at this inspection.

Care plans were not being audited therefore issues with care plans and risk assessments were not being identified. This meant the provider could not be assured they could identify and act on incorrect, inconsistent or out of date information.

Processes to ensure people were being supported in a safe environment, were not always effective. Communication with the landlord around environmental safety was not always effective.

Systems to ensure people were being supported by safe and effective staff, were not always effective. This included oversight of staff training and the number of staff needed to deliver person centred care.

Systems to ensure incidents were investigated and actions taken were not always effective. This meant the provider could not be assured that incidents were being investigated effectively and that actions or learning from incidents were being taken. This also meant incidents could not be audited effectively.

Safeguarding systems were not always effective. Learning from safeguarding incidents did not always lead to updates in people’s support.

Systems to ensure people received their medications safely and in line with their needs, were not always effective. Medicines procedures and practices were not being audited. This meant the provider could not be assured it could identify and act on medicines issues.

Systems to ensure consent had been sought or the principles of the Mental Capacity Act 2005 had been followed, were not always effective; specifically, regarding the use of closed-circuit television (CCTV) in communal areas. This meant the provider could not be assured it had considered the requirements of GDPR, people’s consent or dignity in relation to CCTV.

The provider had carried out a quality audit when they took over the service and identified improvements were required in areas such as care plans and risk assessments, incident management, staff training, and medicines management. However, there was no action plan to demonstrate how these issues were being addressed.

The service 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.

Staff told us about how they felt they were part of a positive community working to provide good support for people. The registered manager told us, “We collaborate and are developing good working relationships with our learning disability and autism partners.” One staff member told us, “I came to work with [service] because I could see people were now receiving better care at Eskdale House.”

The service had an inconsistent approach to continuous learning, innovation and improvement across the organisation and local system.

The management team attended management forums and met with learning disability and autism services in both the public and private sectors. The registered manager told us, “We meet internally and with private sector organisations and share learning.” However, as the service did not always have effective systems to learn from incidents, it could not effectively contribute to innovation and improvement across the organisation and local system.