Ermington House

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

The service was not always well-led and continues to be requires improvement in this key question. We identified 3 breaches of regulation. Whilst a range of audits were undertaken as part of a quality assurance process including systems like daily walkarounds, these and a lack of stable leadership in the form of a registered manager, had either not identified or addressed the issues of concern we found on our visit relating to cleanliness and safety of the environment, medicines management, and people not always experiencing kind, compassionate care.

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.

Most staff were positive about the trainee manager. Comments included, “I think [trainee manager] is good. Very thorough and her communication is spot on”, “A lot of the time she is in the office with the door closed so not often on the floor”, “[trainee manager] is better than the previous managers and she has put in so many changes and everyone is more efficient in their work now” and “[trainee manager] has kept us focused on what more can be done and where we can improve. I think [trainee manager] is doing a brilliant job.” The trainee manager told us they kept themselves up to date by attending the providers managers briefings, completing mandatory training and training provided by the NHS. They told us they led by example, their door was always open, and they regularly completed managers walkarounds to ensure staff demonstrated their vision, culture and values.

The service had not had a registered manager in post since August 2021. This meant the legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service was run, was the responsibility of the registered provider. At the time of the site visit the service had a new manager who was being supported by the provider, nominated individual and managers from the provider’s other services. However, since the site visit the provider informed us the trainee manager was no longer with the service as they did not meet their expectations. Since the last registered manager was in post the provider had unsuccessfully tried to recruit several potential managers to support and lead the service. However, despite a range of audits undertaken as part of a quality assurance process including systems like daily walkarounds, the lack of stable leadership support in the form of a registered manager, had not been effective in promptly identifying the areas requiring improvement we identified during this assessment.

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.

Although staff were able to describe their roles and responsibilities, we saw their practice did not reflect what they told us. The checks carried out did not identify the issues we found. The management team were open and receptive to our feedback. Staff confirmed they were kept up to date with information affecting the overall service via staff meetings, supervisions, and conversations with managers.

Since the last inspection in 2023 the provider had improved their governance systems and processes in relation to monitoring care and care delivery. However, whilst we saw improvements in relation to managing and monitoring risk, the providers quality assurance processes had failed to identify that medicines were not being managed appropriately, people were not always experiencing kind, compassionate care or living in a nice odour and hazard free environment free from the risk of infections. The provider’s 2024 service improvement plan, recently updated by the operations manager, had not identified the concerns in relation to the environment we identified, nor had it recognised that action had not been completed, such as the worn carpets, from their last service improvement plan in 2023. Processes in place to gather feedback from people and their relatives had failed to identify what we found in relation to how people were feeling about their care and interactions they had with staff. The operations manager told us people’s views were gathered during residents’ meetings. However, there was no process in place to gather people’s views anonymously. This is a failure of the governance systems and a breach of regulations. Following our feedback in relation to people’s experience of their care, the operations manager told us they had conducted a resident’s survey following a similar methodology to CQC’s ‘experts by experience’ interaction in order to obtain a “lived experience” account from people. The operations manager told us they held relative’s meetings and surveys were sent out to people’s relatives each year. The operations manager told us since the last inspection they had worked hard to strengthen their governance systems focusing on how they could identify gaps in care delivery, to investigate why assessed care had not been delivered when it should and act immediately to address issues.

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.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.