Archived: Ermington House

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 remained Requires Improvement. We identified an ongoing breach of the Good governance regulation.

This meant the management and leadership was inconsistent. Leaders and the culture they created didnot always support the delivery of high-quality, person-centred care.

This service scored 50 (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 communicate their direction and strategy for the service with staff. This had led to staff not feeling involved or their ideas being listened to.

Information was communicated and shared with staff through handovers, group supervisions and meetings. Staff we spoke with expressed a high level of dissatisfaction with their employment and were not positive about the direction and culture of the service. Staff told us the provider and management level communication was poor and non-inclusive. The provider attributed this to the current performance management being undertaken, however the feedback received was consistent from all staff we spoke with. When asked, one staff member described the service as, “Heartbreaking, exhausting and toxic.”

The provider sent us a staff survey overview but only 3 staff had responded. Results were mixed with a low score on recommending Ermington House as a good place to work and more gave less positive feedback when asked if staff felt people at the service were well cared for.

Leaders did not always embody the culture and values of their workforce. Leaders did not always have the credibility to lead effectively.

People and staff we spoke with told us they had less than positive experiences with the service leadership and management and the feedback we received reflected this. The registered manager was absent from the service at the time of our assessment and there was an interim manager in post.

Staff we spoke with were not always positive about the leadership and management, which the provider attributed to performance management. Staff comments included, “I cannot talk to management now as they have no time and the office door is always closed.” One person told us that while the team leaders were 'exceptional, very empathetic', they found it difficult to trust the management team and found them condescending at times.

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

People gave us mixed feedback about being able to speak up at the service. We saw there were meetings in place that allowed people to contribute to the running of the service; however, some people were unaware of this. One person said, “I don’t think there have ever been any meetings or questionnaires since I have been here.” Some people told us that despite speaking up and requesting repairs to be made in their bedrooms, no action had yet been taken. Other people we spoke with did not raise any concerns about being able to speak up. However, we asked one person who was sitting noticeably uncomfortably if they would like a pillow or support from staff. They responded by saying,“I don’t like to ask, that’s why I keep quiet. I get nervous which is why I didn’t ask.”

Staff feedback about being able to speak up was not positive. Without exception, staff outside of the management chain told us they did not currently feel able or confident to speak with the service management. One staff member said, “Unfortunately, in the past concerns and discussions are shut down and staff are not heard.” Another commented, “Management are often busy and not always supportive. I feel they are under a lot of pressure.”

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.

Whilst we identified there was a high level of dissatisfaction and low morale at the service, there was no indication of inequality towards any staff members. The interim manager and provider were dedicated to supporting all members of their team. Staff all received the same opportunities to train and develop themselves. The provider told us staff were encouraged to contribute to service development through regular staff meetings and events.

The provider did not always have clear responsibilities, roles, 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.

At our previous assessment, the provider breached the regulations relating to good governance. At this assessment, there were insufficient improvements relating to governance and the provider remained in breach of that regulation.

A series of audits were carried out within the service, and the interim manager, nominated individual and provider had oversight of this. However, these audits had not been fully effective. People were placed at risk by the lack of oversight of repositioning records. Some care records contained contradictory information, or key information was missing, which would have been identified by an effective audit.

Daily walkarounds were being undertaken, however these had failed to identify or result in any action being taken in relation to environmental safety concerns. These included infection control concerns, call bells not being in reach in accordance with people’s care plans and hazardous and potentially harmful liquids being kept in an insecure room.

Whilst we did not identify any impact on people, the absence of a fully effective governance system placed people at risk of unsafe or poor care. The provider had a service improvement plan in place, but it was not evident this was driving improvement in outcomes for people. This contributed to a breach of regulation in relation to good governance.

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

The service worked with local GP surgeries and other healthcare services where required. Healthcare professionals who responded to our feedback request told us whilst there was a slight improvement over the previous few weeks, working relationships with the provider were difficult. We received some positive feedback about how staff followed the direction of the professionals who attended the service to support people. Healthcare professionals commented staffing was an issue in the service and communication could be difficult at times. One told us, “I do not believe the service is safe nor effective. I have raised concerns and been through whole home safeguarding [with Ermington House] more than any other.” Another commented, “I feel education for staff has been an issue, and even when completed staff have not been especially forward thinking.”

The service was in a whole home safeguarding processes. The provider elected not to engage directly with the local safeguarding team during meetings to ensure safeguarding concerns for people were discussed with a view to improving quality and safety at the service. The provider instead instructed legal representation to speak at these meetings on their behalf. This did not evidence a willingness to work in partnership with other agencies to improve outcomes for people.

Links within the community were continuing to grow. A local school had engaged in a ‘pen pal’ scheme with people at the service and a local cub scout group were visiting people near Christmas. The local Vicar attended the service weekly.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

The provider did not have an effective system or plan in place to monitor and improve the quality and safety of the service. Whist some areas of the service environment had improved since our last assessment and some areas of the service had improved in safety, for example medicines management, further work was required.

Monitoring systems, whilst in place, were not fully effective and had not identified the issues we found during the inspection as detailed in the various sections of this report. There was a service development plan in place along with an ongoing maintenance plan, however this did not evidence a pro-active approach to improving people’s safety, quality of life and improving the environment. For example, an audit completed prior to our assessment identified one person’s care records did not identify how the person expressed pain, their end of life preferences and actions to take following an identified medicines error. This key information was recorded as 'low' priority and the target date to address these issues which would improve quality and safety was 2 months. This meant immediate improvements to reduce risk or improve outcomes for the person were not prioritised.

On reviewing the maintenance records, it was evident that work to improve people’s standard of living was not assessed as being required quickly. For example, flooring issues identified in bedrooms and bathrooms in December 2024, and January 2025 had still not been actioned or completed. Some basic maintenance tasks and room enhancements, for example painting or replacing a bedside table, had been given a target date for completion of 8 months.