Edgecumbe 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 remained requires improvement. This meant governance was inconsistent and not always effective to monitor the quality and safety of the service. The service was in breach of legal regulation in relation to notification of other incidents, because incidents were not always notified to CQC as required. The provider was previously in breach of the legal regulation in relation to good governance. At this assessment we did not identify sufficient improvement, and the provider remained in breach of this regulation.

This service scored 61 (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. The aims, objectives and core values of the service were outlined in the provider’s statement of purpose. Staff demonstrated these values in their practice, which we observed. A person said, “Anything I want they will do or get done. The staff are very good; I have no complaints and would recommend.” A relative said, “I am delighted with the care.” The provider explained how they had been working to embed the company values into day-to-day processes such as staff induction and supervision to create a supportive and inclusive culture. The provider respected people’s human rights and promoted diversity across the organisation. Staff worked well together and told us morale within the team was positive. A staff member said, “We help each other. There is teamwork.”

Whilst the provider had inclusive leaders who understood the context in which they delivered care, treatment and support, and who embodied the culture and values of the organisation, leaders did not always demonstrate the skills, knowledge or experience required to lead effectively. During the assessment, the provider did not demonstrate sufficient knowledge of the types of incidents or events that needed to be notified to CQC. This issue had also been identified at the previous assessment. We raised this with the provider, who assured us they would prevent any recurrence by introducing new processes and implementing learning actions. During our visits to the service, leaders were visible and supported the assessment. They were open, honest and responsive to our feedback. There were changes in the management team since the last assessment. The former registered manager had left their post. A new manager had been appointed and was in the process of registering with CQC. People, relatives and staff spoke well of the management team and told us they were approachable and supportive. A staff member said, “Management team are very proactive.” A professional said, “I found them to communicate well with me and were always warm in their interactions.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There were established systems to support staff in speaking up, including supervisions, staff meetings, and surveys. Staff told us they felt able to raise any concerns with managers. A staff member said, “If we raise something, they take action.”

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 explained how they promoted staff wellbeing and supported the diverse needs of staff, including those with protected characteristics. This included offering an employee assistance programme, recognising staff achievements, dedicated support for staff recruited from overseas, and enabling flexible working arrangements for staff with health conditions and specific religious beliefs. Staff told us the management team was approachable and supportive. A staff member said, “Yes, we are supported well.”

The provider did not always 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 carried out a range of service level and provider audits to monitor the quality and safety of the service. However, these audits did not identify, or address shortfalls found during the assessment. For example, they were not effective in identifying and resolving issues we found with risk assessments, incident records, and notifications not submitted to CQC. We were not assured systems to monitor staff training were effective, as records were not sufficiently robust or up to date, and we identified gaps in staff training records. Although the provider had an action plan and some issues had been identified, timely action had not been taken to rectify them. Governance processes had led to some improvements since the last assessment, such as in medicines management, staff supervision, induction, and recruitment. A new system of policies and procedures had been introduced, although the incident reporting policy required further work to ensure it reflected incidents recorded electronically. The provider responded positively during the assessment and provided evidence of actions taken to address the shortfalls identified.

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. The provider worked effectively with other professionals and maintained positive working relationships. The service worked in partnership with professionals, including the GP, people’s advocates, and the local mental health team to meet people’s individual needs. The provider explained they took part in provider forums to share best practice and arranged social events to support the development of a wider service community. Professionals told us they had positive working relationships and effective communication with the service. A professional commented, “Yes, I have always found [management team] approachable and contactable.”

The provider had not always focused on continuous learning, innovation and improvement in the service. At the last assessment we identified governance shortfalls. At this assessment we found governance processes had led to some areas of improvement, for example in relation to medicines management, staff supervision, induction and recruitment. However, we also identified shortfalls in areas such as risk assessments, incident records, and notifications not submitted to CQC. We found learning following incidents was not always well documented. Further work was needed to establish a consistent culture of learning, innovation and improvement. The provider was committed to delivering a quality service and responded promptly to shortfalls identified during the assessment. A professional commented, “I feel there are always areas of improvement to be made and some concerns, but the team are always trying to make the changes necessary, and are keen to improve, develop and move the service forward and frequently seek help, support and advice as needed to do this.” There were processes to involve and gather feedback from people and their relatives, including a regular newsletter, meetings, and a questionnaire. People, relatives and staff told us communication with the management team was positive. A relative said, “I feel we are being listened to, both [person] and [relative], they understand [person]. I can go in and talk to management if necessary.”