CQC report explained · a residential care home
What the CQC found at Eastham
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2023
Eastham is rated Requires Improvement; inspectors found infection-control and staffing shortfalls, although medicines, safeguarding and recent management changes were positive.
This was an unannounced, focused inspection. The inspector visited on 12 December 2022 and looked only at Safe and Well-led. They spoke with people and staff, observed care, checked care plans and recruitment files, and reviewed audits and safety information.
The home was not always safe because infection-control procedures were not consistently followed. Some equipment needed cleaning, hoist slings were stored in communal areas, and personal protective equipment was not always used correctly. Action was taken quickly after the visit, but inspectors said the improvements needed to last.
There were enough staff for personal care, but staffing levels needed review so people had enough time, activities and social contact. Management oversight had also suffered during management changes, although a new manager was receiving support and audits had improved.
The overall rating fell from Good at the previous inspection to Requires Improvement. The other three question ratings were not inspected during this visit, so their previous ratings were carried forward.
Medicines
People received their medicines safely and as prescribed. Staff training, competency checks, records and audits were in place.
“People received their medicines safely and as prescribed.” from the report
Safeguarding
People said they felt safe. Staff had safeguarding training and knew how to report concerns.
“People told us they felt safe living at the service.” from the report
Recruitment checks
The provider completed the required checks before new staff started work.
“Relevant checks were completed before a new member of staff started working at the service.” from the report
Learning from incidents
Accidents and incidents were investigated, with learning shared with staff to help prevent repeat problems.
“Staff shared learning through regular meetings, handovers and information sharing to promote safer care.” from the report
Positive working culture
Inspectors found people, relatives, staff and professionals working well together, and staff felt supported by the manager.
“There was a positive culture of staff, people, their relatives and professionals all working well together.” from the report
Infection control
seriousSome hoists and wheelchairs needed cleaning, slings were stored in communal areas, and PPE was not always used safely. The provider acted after the inspection, but needed to keep these improvements in place.
“One staff member did not change their PPE when going into or coming out of a bedroom of a person who had COVID-19.” from the report
Staff time and activities
needs fixingStaffing was enough for personal care but not always enough to provide quality time, company and meaningful activities. Inspectors recommended better contingency plans for daily activities.
“There are just enough care staff to care for people's physical needs but I do worry about how lonely people get as we just don't have the time to spend quality time with people, it's very sad.” from the report
Management oversight
needs fixingManagement changes had reduced the quality of oversight, and existing systems had not identified the infection-control shortfalls. New audits were in place, but practices still needed time to become established.
“The provider had not ensured that there had been appropriate systems in place to identify the shortfalls we found around infection prevention and control on the day of inspection.” from the report
Involvement in daily life
needs fixingSome people were not sufficiently engaged in activities and could spend time walking and then being returned to the same chair. The report also said people's lifestyle and culture were not fully recorded.
“However, people could be more involved and engaged in day to day activities to increase their sense of purpose and independence.” from the report
- 01What checks now confirm that wheelchairs, hoists and hoist slings are cleaned and stored safely?
- 02How do you make sure staff change and use personal protective equipment correctly, especially during a COVID-19 infection?
- 03What staffing levels are planned for each shift, including when staff are absent or the activity coordinator is covering other duties?
- 04What meaningful activities are available every day for people who may be at risk of loneliness or isolation?
- 05What evidence can you show that the new manager's audits and care improvements have been sustained?
This was an unannounced focused inspection of Safe and Well-led only; the other three question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 8 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2021
Targeted inspection found good infection control; the home was inspected but not rated.
Inspectors made an unannounced visit on 27 January 2021 after receiving specific concerns. They looked at infection prevention and control, spoke with management and staff, contacted outside professionals, and checked records.
They found that the home was following infection control guidance. Staff used personal protective equipment safely, testing was available, furniture had been rearranged for social distancing, and there was enough protective equipment.
The home’s previous overall rating was Good, published in April 2020. This targeted inspection did not change that rating and was recorded as inspected but not rated because it did not cover the whole service.
Infection control
Inspectors were assured that the home had suitable arrangements to prevent and manage infections.
“We were assured the service was following correct infection prevention and control guidance and policy to protect people from infection and prevent the spread of infection.” from the report
Protective equipment
The home had enough protective equipment, with stations for putting it on and taking it off safely.
“The service has adequate personal protective equipment. Contaminated PPE is disposed of correctly in clinical waste bags.” from the report
Testing and training
People using the service and staff could access testing, and staff had received training in using protective equipment.
“The provider has provided staff PPE training alongside training provided by the NHS.” from the report
Social distancing
Furniture and dining tables had been rearranged, and signs helped people understand which chairs should not be used.
“The Layout of the furniture had been changed to encourage social distancing.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you currently prevent and manage infection outbreaks?
- 02How do you make sure there is enough protective equipment for staff and people living here?
- 03What testing arrangements are available for residents and staff?
- 04How are staff trained to put on and remove protective equipment safely?
- 05How do you support people who walk with purpose while also managing infection risks?
This was a targeted inspection of infection prevention and control within the Safe key question; it did not review the whole service, and the previous Good rating was not changed. This explanation was written from the published report of 10 March 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Eastham
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- February 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- April 2020Goodstayed GoodSafe: GoodWell-led: Good
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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