Eastfield

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

Although the registered manager completed checks and audits on the service these were not effective in identifying and addressing the widespread issues highlighted within this assessment. For example, medicine audits did not identify and improve issues including people running out of their medicines. There was a closed culture within the service, which created poorer outcomes for people. This had not been identified and addressed by the registered manager. We found one breach of the legal regulation in relation to good governance.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff did not have a well-developed understanding of equality, diversity and human rights, and they did not prioritise safe, high-quality, compassionate care, which impacted on the culture of the service. For example, one staff member referred to people with continence needs as ‘wetters’.

Systems in place to ensure that the culture of the service was positive were not always effective. Care records, daily notes, and feedback from staff demonstrated that some of the care people received was institutionalised. For example, there was bath schedules for people to wash, which is not person centred. The registered manager had not identified these practices, including ‘tea rounds’ and routines to people getting up for the day.

Staff we spoke to expressed that they were generally happy with the support they received from management. However, Leaders did not have the appropriate knowledge, and skills to lead the service effectively. The registered manager had not identified the significant and widespread issues highlighted within this assessment.

Leaders were not alert to examples of poor culture that affected the quality of people’s care and could have a detrimental impact on staff. For example, the registered manager had not identified that staff used poor and inappropriate manual handling techniques when supporting people to walk and transfer. The registered manager failed to identify that processes were not in place to ensure risks within the service were well managed.

While the staff we spoke to expressed that they were able to raise concerns, we found that staff and the registered manager did not always identify concerns and share these. For example, poor manual handling techniques had not been identified by staff or the registered manager. Staff using inappropriate language to describe people they supported without challenge from staff or leaders.

Whilst the provider had a whistle blowing process in place, this was not effective as not all concerns had been shared and identified by staff and the registered manager. We observed poor manual handling techniques, which were not highlighted by staff. Staff used poor language to describe people’s needs and this had not been identified and addressed. Staff and the registered manager had failed to report and act on concerns relating to one person self neglecting.

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.

The registered manager completed ‘daily health and safety checks.’ However, these were not reflective of the service that we found. For example, it was noted that there were no malodours over the 10 days checks were completed, however we found that parts of the service were highly odorous. Bedroom checks were completed, however despite no issues being identified, 2 rooms were checked twice in 10 days, and other rooms were not checked at all. Not all rooms were checked by the registered manager. Personal equipment was checked; however we found a number of rooms where people did not have a toothbrush.

Although the registered manager completed checks and audits these were not effective. The registered manager completed monthly weight audits for people, however they failed to identify that one person had lost 5.5kg of weight, and their MUST assessments identified they needed a referral to a dietitian or healthcare professional; however no referral had been made. The registered manager failed to review bowel movement charts and ensure that appropriate action was taken to address the risks to people. The provider had a new electronic system, which highlighted when people’s bowels had not opened, however these were not being monitored. The audits completed failed to identify that people were not being supported with pressure care and oral care in line with their care plans. Medicine audits failed to identify the issues highlighted within our assessment including people missing medicines, urine being stored in the fridge and prescribed creams not being in stock and not being used. Notifications were not consistently submitted as required to external organisations, including the local authority safeguarding team, and CQC.

Whilst staff told us they worked well with healthcare professionals, we found that this was not always the case. Communication with external healthcare professionals was not always effective and impacted on people.

Prior to our assessment, we received information of concern from a number of different partner agencies in relation to the care delivered at Eastfield. This included feedback from healthcare professionals and the emergency services raising concerns about the quality of care.

Whilst the registered manager told us they had good working relationships with healthcare professionals including the district nurses, there was sometimes a lack of communication. For example, there was a lack of communication and knowledge in relation to medicine and prescribed creams. Communication between the service and the GP was not always effective, as one person ran out of their medicine.

Although staff told us they reported incidents and accidents, communication to ensure that incidents were known was not always effective. For example, when staff completed ABC charts the registered manager was not always aware. The recording of some incidents was not detailed enough to ensure that trends and learning could be identified and shared with staff. We received mixed feedback from staff in relation to developing skills and knowledge. For example, some staff told us that they had not had training in people’s health needs including dementia.

Process to ensure that lessons were learnt and improvements implemented were not robust. For example, ABC charts were completed by staff, and these were not reviewed by the registered manager, due to their electronic system not highlighting them. The registered manager had not identified that this process was not working, and the communication between them and staff was ineffective. There was not sufficient learning in relation to distressed behaviour. For example, there had been a number of incidents where a person had become distressed, when we discussed these with the registered manager they told us incidents had not occurred how they were described. The registered manager told us they needed further investigation, as they had not been made aware of some incidents. There was limited evidence relating to actions taken to address or mitigate identified risks. For example, the falls analysis completed in September 2024 detailed that there were no trends or patterns to review. However, nearly half of the falls happened in the bedroom’s downstairs, and a quarter of the falls happened between 06.00–09.00am. The analysis for August 2024 also showed that the majority of falls occurred during the same time period of 06.00-09.00am.