Earlfield Lodge

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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 identified one breach of regulation. The provider had systems and audits in place, however improvements were needed. They were not effective and fully embedded. Some audits lacked essential information and timelines. The systems the provider had in place had not identified the shortfalls which we found. Many actions were still outstanding on the provider’s action plan and the approach of the provider was sometimes reactive instead of identifying issues. This was a breach of regulations relating to good governance. The improvements made by the provider had been slow. The home had a stable manager in post since June 2023. The service has remained in institutional safeguarding procedures with the local authority. The local authority quality assurance team had devised an action plan to support improvements. The service continued to work towards this. We have spoken with the provider about the support for the registered manager. We asked the provider to review the support in place, given the number of actions outstanding.

This service scored 46 (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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

We received positive feedback from the staff. They were overall positive about the staff team, management, provider and the deputy. They felt things had improved as a team. One staff member told us, “They want new ideas; this is why staff meetings are important. I’d say that we are encouraged. The provider is enthusiastic and wants new ideas all the time. There is a suggestion box for staff and residents and visitors etc”.

The quality assurance systems that were in place were not effective. A wide range of audits were being carried out by the registered manager and deputy. The audits had not identified a number of shortfalls which we identified. The environmental risk assessment undertaken dated July 2023 had not identified the exposed pipes which we found. The risk assessment stated hot pipes accessible to people should be adequately boxed in and covered to prevent contact with hot surfaces with regular checks undertaken. These checks had not been adhered to. The provider had a refurbishment plan in place dated April 2024. This had not identified some areas of the building that needed attention and maintenance. This included inside and the outside garden areas. For example the refurbishment plan listed that a smoking area was needed. No timescales were recorded, and the provider had not taken action to ensure this was a priority due to the risks associated with smoking. This went against the provider’s smoking risk assessment. Care plan audits were being undertaken by the staff and the registered manager. The system was not effective and failed to identify where risk assessments and care plans lacked important information. We identified a number of shortfalls where risk assessments did not contain information about risks to people. This included for example, one person’s skin risk assessment and another person’s mobility assessment. They were not accurate and up to date The systems used to monitor recruitment checks of staff was not robust. We identified a number of shortfalls where recruitment records lacked essential information. This included not following up on gaps in employment and missing information. Checks undertaken had failed to ensure the recruitment of staff was safe. The provider had carried out a recruitment audit, which had identified the shortfalls. However the actions had not been completed.

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.

The provider was working closely with the local authority safeguarding and quality assurance team. The local authority told us they felt it was a “hand holding” approach, where they were identifying issues and pointing out where improvements were needed.

The service had an action plan in place which they were working towards. This was devised by the local authority quality assurance team. This was rated in terms of risk priorities. The action plan contained a number of actions outstanding. Improvements implemented had been slow and were not always effective. The service had its own action plan in place. An independent audit was carried out by an external provider, this was to give an independent view of the concerns the local authority had identified. The progress in putting actions into place had been slow. As well as managing the day to day service, the registered manager was trying to implement changes. These had not always been effective and the service continued to have a history of non-compliance with the CQC. The systems used to monitor recruitment checks of staff was not robust. We identified a number of shortfalls where recruitment records lacked essential information. This included not following up on gaps in employment and missing information. Checks undertaken had failed to ensure the recruitment of staff was safe. The provider had carried out a recruitment audit. This had not identified the shortfalls. We found the provider’s paperwork and external information was under a different company name. This company is not registered with the CQC. We spoke to the provider and asked them to change this as it could be misleading for the public and staff. We found the provider’s company address was not up to date. We checked the information held on Companies House and the address did not match the registration certificate of the provider. This was rectified during the inspection. The provider did not have a website listed with the CQC. There was no assessment rating displayed. This was rectified during the assessment. The provider’s statement of purpose was not up to date. It referred to the previous registered manager.