Eastdale Healthcare's first inspection rated it Requires Improvement overall, with shortfalls in risk assessment detail, recruitment references, PPE compliance and governance audits failing to detect these issues. Effective, caring and responsive domains were rated Good, with positive feedback from people and relatives about staff kindness, training and management responsiveness.
Concerns (6)
moderate
Care planning
: “assessments were not fully detailed. For example, for people with mobility needs, there was little information as to how to assist them.”
moderateGovernance: “they were not always effective as they had not identified issues we found including the lack of detail in safety risk assessments, staff non mask wearing”
moderateInfection control: “Everyone, except one person, told us staff wore personal protective equipment (PPE) during the COVID-19 pandemic”
moderateRecord keeping: “references for one staff member had not been sought from the last employer, which could have revealed issues of concern.”
minorPerson-centred care: “there was little information about people's past employment, interests and hobbies.”
minorComplaints handling: “The procedure implied however that Care Quality Commission investigate complaints. This is not the case as CQC cannot, by law, investigate individual complaints.”
Strengths
· Staff trained and competency-tested in medicine administration; people received prescribed medicines safely
· People and relatives reported staff were kind, caring and respected dignity, privacy and independence
· Enough staff employed with no missed calls reported
· Staff understood safeguarding and how to report concerns
· Registered manager promoted an open, inclusive culture and was responsive to feedback
Quality-Statement breakdown (23)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongGood
safe: Using medicines safelyGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; supporting people to access healthcareGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Continuous learning and improving care; promoting a positive person-centred cultureRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood