Easterlea

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• 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

We found 1 breach of the Regulations. The provider no longer had effective governance arrangements in place to identify shortfalls or help drive improvements. There was a lack of organisational vision to ensure care and support was delivered in line with evidence based practice and standards. Policies and procedures which help to ensure that staff and leaders are clear about their role and responsibilities needed to be updated. There had been a failure to notify the Care Quality Commission in a timely way of safety related events that had occurred within the service. Records relating to people’s care were not always sufficiently detailed, person centred or drafted in line with good practice standards. The provider’s representative told us of plans to enlist someone with suitable expertise to help develop governance systems including human resources management, which will support the registered manager and deputy manager in their roles. They also told us of plans to link in more with the provider’s other care home service, to promote shared learning. However, most staff spoke of a positive, person centred, culture within the service and of a sense of trust and confidence in the skills of the leadership team who they felt were visible within the service, supportive and made them feel valued. Staff told us they were encouraged to raise concerns without the fear and team meetings could be used to share suggestions or ideas.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Overall staff spoke of a positive, person centred, culture within the service. One staff member said, “I love working here… this home is really person centred, there are a lot of staff with a lot of empathy who genuinely care for the residents” and another said, “There is a lovely staff team who enjoy looking after the residents…Staff aren’t forced to do this, they want to”. Staff mostly spoke of a sense of trust and confidence in the skills of the leadership team who they felt were visible within the service, supportive and made them feel valued. For example, 1 staff member said, “The management are really supportive and will give extra direction, they are always there to listen” and another said, “Yes I feel fully supported, I wouldn’t stay if I wasn’t”. However, 2 staff raised some concerns about the culture within the home which they felt was not being addressed by the leadership team. One spoke of a divide between the day and night care team, and another said, “You raise something and are tarnished with meddling.” We asked the deputy manager to tell us about the values and ethos of the service. They told us the service was a small family business, focused on care. They said staff recruitment interviews focused on this. The registered manager told us they had 1 supervision / appraisal meeting a year with the provider. They told us this was sufficient as they could ask for support at any time.

There was insufficient evidence that the provider had robust systems and processes place to ensure the continued professional development of the registered manager, for example, they were only receiving supervision from the provider once a year. Supervision is important to ensure the registered manager remains suitably skilled and knowledgeable, is kept updated on best practice and is able to meet the challenges of the role. We identified some areas where the registered manager was not up to date with national legislation, evidence based good practice and required standards. For example, knowledge of the requirements of the Mental Capacity Act 2005 and its Code of Practice needed to be further developed. The registered manager has accessed additional training on this for themselves and the deputy since the assessment was undertaken. We found evidence that a number of notifications had not been submitted in a timely way to the Care Quality Commission as required. As noted above we found that medicines were being pre-dispensed by the night staff for the day staff to administer the following morning. This is not safe or good practice, but records show the registered manager was aware this practice was happening, but they had not taken steps to address this. The registered manager had not appropriately escalated a safeguarding concern to relevant agencies in a timely manner. We identified a number of policies, systems and processes that needed to be reviewed and updated to ensure they provided adequate support and guidance for staff. We reviewed a complaint and noted that when responding to this, the registered manager had breached the confidentiality of another person using the service.

Overall, staff told us they were encouraged to raise concerns without the fear they would be blamed or that there would be negative implications for doing so. One staff member told us there had been “No negativity towards her as a consequence” for a raising a particular concern. Another staff member told us the registered manager “Always advised that the best thing to do was to report any error.” Most staff were confident the leadership actively listened to concerns and where able acted upon these. For example, 1 staff member said, “If I had a problem, I would go to either the manager or the deputy manager, they both would listen to me”. As reported elsewhere in this report an example provided by a staff member of the leadership team acting on feedback from staff was increasing staffing levels at weekends. They said, “They [The registered manager] has resolved the issues and has done something about it.” Staff told us team meetings could be used to share suggestions or ideas. One staff member said, “We have regular team meetings 3 times a year… there is also a suggestion box which is anonymous to raise anything. In the meetings we have open time, and we will be asked if there is any suggestions.” Another staff member told us they had suggested about new games to develop the activities provision. They said the management team had ordered these and they had been enjoyed by people using the service. The deputy manager understood the principles of the Duty of Candour when we discussed this with them.

There were systems in place to enable staff to voice concerns. This included team meetings, supervision, and staff surveys. A whistleblowing policy was in place.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us they were clear about their role and responsibilities. staff member said, “[Our role] changes all the time with residents, but it is always made clear what is needed” and another said, “Yes, it is clearly laid out, if I had a problem I can speak with to management, and they will run through things with me.” The registered manager told us a programme of supervision and observation of staff practice was in place to ensure they maintained oversight of the behaviours and performance of staff. Staff confirmed this with 1 staff member telling us, “Usually in supervision, if someone has put in a letter of thanks, [Registered manager] will let it be known, it feels nice that we get positive feedback and it encourages us to do more” and another said, “There is always room for growth and for new responsibilities which will be fed back in supervision”. Although the registered manager could describe some quality assurance processes, we found these were not always sufficient or effective. The registered manager told us that either the deputy manager or a senior carer completed quarterly wellbeing audits with each person to seek their views about their care and support. Records of these meetings were limited and so it was not possible to be confident about the impact of these on driving improvements.

Some quality assurance and governance arrangements were in place, but these were not always being effective at identifying shortfalls or driving improvements. A comprehensive health and safety audit was undertaken by an external consultant in August 2023, but some of the recommended actions from this were yet to be completed. When Hampshire Fire and rescue Service visited the service in July 2024, they identified a small number of shortfalls with fire safety. The local Integrated Care Board (ICB) had undertaken a pharmacy audit of the service in July 2023. This had identified a number of areas where improvements were needed. Some of these had not been addressed by the time of our assessment in May 2024. We identified concerns with oversight of safeguarding concerns, falls and medicines management. Records relating to people’s care were not always sufficiently detailed, person centred or drafted in line with good practice standards. These concerns had not been picked up by a robust system of audit or review. Whilst the home was observed to be clean, no infection control audits were taking place as required by the providers infection control policy. We found a number of occasions where notifications of incidents or safety related events had not been submitted to the Care Quality Commission in a timely way. Policies and procedures were not always written in sufficient detail to support management and staff in their roles and responsibilities. The registered manager acknowledged that improvements were needed in their governance processes and since the inspection they have informed us of a number of improvements they are planning. These will need to be embedded to ensure that they provide an effective tool for identifying shortfalls and driving improvements.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Most staff told us they were encouraged to speak up with ideas for improvement and innovation. Comments included, “Yes you can feed in any ideas on how to improve the service,” “They do look for ideas on how to improve or what they help with” and “Registered manager] is very good at taking on board suggestions and making improvements where possible.” However, 2 staff felt their views were not always listened to or if they were, the improvements did not always last. Staff felt, overall, they were provided with appropriate support and given opportunities to develop in their role. For example, 1 staff member said, “There are opportunities to do [qualifications], [Registered manager] encourages people to take this up” and another said, “They will give appropriate time for staff to pursue training”. The provider’s representative told us of plans to enlist someone with suitable expertise to help develop governance systems including human resources management, which will support the registered manager and deputy manager in their roles. They also told us of plans to link in more with the provider’s other care home service, to promote shared learning.

The registered manager had a lack of professional curiosity about the root cause of incidents and accidents that occurred within the service. Whilst there was evidence that the registered manager acted on suggestions from staff and had implemented new initiatives in response, overall, there was a lack of evidence that the registered manager and provider had a clear vision for the direction of the service. There was no service improvement plan in place that prioritised areas for improvement or planned longer term innovation. We were sent a quality assurance document which said twice yearly quality review meetings were held with the provider and the provider’s other home to review audits and share learning from complaints and feedback from questionnaires as well as conducting a review of all policies and procedures. The minutes of these meetings did not provide assurances that this was the purpose of these meetings which were more a review of the financial position of the business. More needed to be done to ensure there was a robust quality assurance system in place that was effective at driving improvement in the service. There was evidence that staff and people using the service and their relatives were asked for their feedback about the care provided. This included quarterly wellbeing reviews with people and annual quality assurance surveys. There was however a lack of evidence of how this feedback was used to develop and improve the service. Staff meetings had been held twice over the last year and there was some evidence that these were used to enable staff to make suggestions, but also to share learning from audits of the service. For example, in 1 of the meetings, the registered manager had shared findings from a pharmacy audit with staff.