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

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 in June 2023, we rated this key question requires improvement. At this inspection, the rating has remained requires improvement. This meant that we found governance and accountability systems were still not always effective and did not identify or address other issues we found during our assessment. We found 1 breach of legal regulations in governance. Governance systems were not always effectively used to assess, monitor, and improve standards or mitigate risk. The service had made significant improvements since the last assessment to quality assurance systems to provide better oversight of the service.

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 home had undergone significant changes in management in recent months before our assessment. A new manager had been appointed and was prioritising making improvements to the service. The management team were committed to creating an open and transparent culture within the service. The manager and nominated individual were responsive to concerns raised following our site visits. The provider was investing in the service, acknowledging previous shortfalls, and ensuring a robust approach to improvements. Staff told us there was a positive culture of working together as a team.

Regular team meetings helped staff feel involved and supported. A staff survey was conducted annually, and the results were fed back to the provider. The manager told us they had set up opportunities for staff to have informal conversations with them on a weekly basis.

Since the last assessment, the manager had submitted an application with the Care Quality Commission to become a registered manager for the service. The provider had been actively working with the local authority to address concerns identified with the support of an external consultancy company. The service had a service improvement plan to track ongoing refurbishment developments and ensure the required measures were taken to maintain the service to a safe standard. The nominated individual and manager were responsible for ensuring these developments were completed. Staff told us they felt supported throughout the ongoing changes to the service. One staff member told us, “It is better now; the manager is very supportive, and I feel listened to.”

The management team acknowledged that there were inconsistencies in processes and policies. This was due to a whole service change around governance. The management team recognised they ‘had a lot of work to do and were on a journey.’

Staff told us they felt listened to and were encouraged to speak up. Staff told us they understood how to report concerns about the home and felt able to approach the management team with them. The service had a whistleblowing policy should staff not feel able to approach the management team or wider organisation. Staff knew they could contact other external agencies such as the local authority, police or the CQC if they wanted to raise concerns about the safety or culture of the home.

There were systems in place to gather feedback such as team meetings, handovers surveys, communication book and supervisions. The service had a complaints process. The service had systems to log and investigate complaints however, there had been no complaints for the last 3 months.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff expressed no concerns around discrimination or bullying within the service. Staff said they were treated fairly, and morale was good. A staff member told us, “We are like a family here.” The wellbeing coordinator also supported staff where English wasn’t their first language by providing further enhanced learning.

The manager and deputy manager actively encouraged workforce participation and engagement. We saw there were regular celebrations of ‘employee of the month’ and employee birthdays.

Staff spoke positively of the impact of the new management team. The management team told us that they had made improvements to their quality assurance systems since the last assessment with the support of an external consultancy company. They told us they had been working closely with the local authority to make improvements to the service in relation to governance and management. The management team was open and transparent during the assessment and acknowledged, whilst improvements had been made, some areas of the service needed further improvements such as care plans, training, recruitment records and supervisions. The nominated individual and provider explained how they were committed to investing in the service and staff to ensure future service development.

We found the service had service level and provider audits and they were being consistently completed. Improvements had been made and sustained in relation to infection prevention control and service environment. However, governance systems did not identify, or address issues found during our assessment. For example, relating to risk assessments, medicines, recruitment, and staff training. We found policies and procedures had not been updated and were not fully embedded and used by staff. CQC notifications were not always submitted as required. Records showed improvements had recently been made since the new manager had started. However, records showed staff supervision had not been consistently occurring in line with procedure. We found induction records were not always fully completed or followed up. The service had adopted an overarching quality assurance audit to monitor the progress and direction of the service. The audit was completed and actioned by the nominated individual to improve the quality management systems within the service and to identify any shortfalls in their business objectives. The management team responded promptly to concerns raised and told us they were committed to making further improvements.

People and relatives told us that they were able to access the community. A relative told us, “There were a few trips, 3 or 4, to the pub last year but not this year. I go in the garden.”

Staff told us that there were visits by the GP and other healthcare professionals on a weekly basis. They told us that they organised a summer party annually and invited the neighbours to attend. This recently took place in July and was well attended by the community; they received positive feedback.

The provider told us they had been working to develop a more open and transparent service that worked in partnership with other organisations. Feedback we received about the service confirmed this.

Staff told us they felt the service had improved since the last 2 assessments and changes had been implemented. The manager had plans to improve and refresh training in key areas and to promote a culture of learning and innovation within the service. They acknowledged there were areas to improve. Systems for learning were not robust as we had identified gaps in training. They recognised that learning from incidents had not always been well documented. The service was working towards focusing on continuous learning, innovation, and improvement. The management team recognised that the focus for the last twelve months had been to improve their governance, environment, and safeguarding processes.

The management team recognised that they had not had the time to improve all aspects of the service, and this was a continuous journey. The provider completed satisfaction surveys annually, and an action plan was created by the provider, based on feedback from people. The manager held monthly resident meetings to gather feedback from people. We will assess the effectiveness of the implementation of the responses from the service at any subsequent assessment visits.