Edgemont House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People received a service that was safe. The registered manager, deputy and staff understood their role and responsibilities to help keep people safe from harm. People were supported to take risks, promote their independence and follow their interests. Risks were assessed and plans in place to keep people safe. People’s capacity to make decisions was assessed and recorded and staff respected people’s choices. There were enough staff to safely provide care and support to people. Checks were carried out on staff before they started work to assess their suitability to support people. Staff received regular supervision and an annual training programme equipped staff with essential skills and knowledge. Medicines were well managed, and people received their medicines as prescribed.

This service scored 66 (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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were happy with the support they received from professionals and felt able to make decisions and choices about their care. One relative told us, “Referrals are made where necessary and as a family we are involved where possible and kept informed of any updates.”

There were good relationships with local authority commissioners, social services, GPs, and other health professionals. The service ensured people had prompt and effective access to primary care, including preventative screening and vaccinations, routine checks, GP call outs and access to emergency services. The registered manager and deputy recognised the importance of seeking expertise from community health and social care professionals so that people's health and wellbeing was promoted and protected. Thorough assessments for those people who were considering moving into the home were completed. The information gathered was detailed and supported the service and prospective ‘resident’ to decide whether the service was suitable and their needs could be met.

Feedback from all community health and social care professionals was positive and supported effective ways of working alongside each other. They told us, “I have had quite regular contact with them over the last 3 years and I visit the home every two weeks. I am confident they are able to recognise acute/severe illnesses and flag these concerns. They use our duty service appropriately and the staff are able to differentiate between clinical scenarios that need same-day action and things that can wait for routine reviews”, “The manager knows the residents well and is a useful source of information. They provide insight to the family dynamics and social circumstances of each resident which is often helpful” and “Communication between staff has improved since they have started using computer software to record observations, weights and clinical requirements.”

The service had systems and procedures to support staff when working with other professionals. Policies and processes about safety reflected joint working with other key partners to promote shared learning and drive improvement. Hospital passports provided records of people’s health needs and were shared with other professionals as required. This helped to keep people safe when receiving treatment and promoted continuity of care.

People told us they were safe and happy with the care and support they received. The home’s survey reflected everyone felt safe and content, and also confirmed that staff treated them kindly with dignity and respect. Staff were very proud of these results. Relatives felt people were in ‘safe hands’. One relative said, “It’s like home from home here and we are so happy with the love that my relative receives, they are thriving in this caring, supportive environment.”

Staff took every precaution to help keep people safe from unnecessary harm. They were kind and ensured people were happy and felt safe. They encouraged people to make choices to reduce risks and stay safe, whilst respecting people's rights to make their own decisions. Staff told us immediate action would be taken to keep people safe should any abuse or neglect be suspected. This included working in partnership with other health and social care professionals. Comments included, “I have no concerns whatsoever. I know that my colleagues do their best with everyone living here. I will always report to the manager if I see anything to do with people’s safety”, “I would report anything that I believe is unsafe practice to my manager. If action wasn’t taken, I would take it further and raise a safeguarding concern with the local authority and CQC” and “I protect others within the service by following the correct protocols.”

Staff understood what constituted abuse and the processes to follow to safeguard people in their care. Policies and procedures were available, and staff had attended safeguarding training updates to refresh their knowledge and understanding. The registered manager and staff recognised their responsibilities and duty of care to raise safeguarding concerns when they suspected an incident or event that may constitute abuse. They notified the relevant agencies including the local authority, CQC and the police.

People were supported to take risks balanced on their safety and health care needs. Capacity had been considered and their right to take informed risks was respected. Re-evaluation, monitoring, and support had enabled people to be as independent as possible, whilst respecting there may be a degree of risk. The registered manager and staff provided examples of a positive, person-centred approach to the management of risk.

Staff confirmed risk assessments contained up to date information to support people safely and effectively. They had a good level of understanding when identifying potential risks, managing actual risks, and keeping these under review and recognised their responsibility to report accidents, incidents, or concerns. They had the knowledge and skills to protect people safely without being restrictive. One staff member stated, “It is important that the individuals we care for are able to have a say in their day-to-day life. It is important they focus on what they can achieve not just the things they can’t do. It is about taking time and one step at a time to get to the desired goal. It is important for us to provide a positive attitude to risk taking and support the individual with this.”

Processes and systems such as handovers, care record reviews, and meetings helped ensure risks continued to be managed safely and were effective in enhancing people’s lives. In addition, the service worked alongside families, significant others and health and social care professionals to help provide a holistic approach to risk management. Written accident and incident documentation was comprehensive. There was evidence of learning from incidents and changes were implemented. Monthly audits helped staff identify trends to avoid further recurrences.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Evidence from confirmed people and relatives felt there were enough staff to support individuals. One relative told us, “The carers are always on hand if my relative buzzes for them and they always usually assist within a few minutes.”

Staff told us there were enough staff working in the home to support people safely and respond to their needs. Comments included, “Staffing levels are good, staff are appropriately trained and work well as a team” and “I think the staffing levels in the home now are good. Staff work well together and have good knowledge and experience.” Morale amongst the staff was positive. Staffing levels were reviewed monthly, when new people moved to the home or if a person’s needs changed. Staff worked additional shifts to help ensure continuity in care by reducing the need for agency staff. Staff received training and updates to help ensure they were suitably skilled. Collectively they had the skills and confidence to carry out their roles and responsibilities effectively and were supported to access additional topics to help enhance the care people received. Comments included, “I had an induction along with training, I felt confident enough to work unsupervised but was reassured by management and the team that if I needed help, I could ask” and “We have a mixture of both in house and online training which I find very helpful. The online training helps me to keep my knowledge up to date and is very good. I also like the in-house training because we are able to get involved with scenarios and take part in activities.” Staff were supported daily by the provider, registered manager, deputy and colleagues. Any additional support or supervision was provided on an individual basis and these were formally recorded. The comments received from staff was testament to how support mechanisms contributed to a positive culture where peoples experience was important to staff. Staff told us, “I would just like to say I am very proud of the team we have here at Edgemont House and we all try our best to ensure the safety of our residents. The team now is so much stronger then when I first started here”, “I have never met managers who are relaxed and approachable, it’s great."

At the inspection of June 2023, we found safe recruitment procedures required improvement. During this assessment we found that improvements had been made and the provider was no longer in breach of our regulation. Systems and processes helped ensure training and supervisions were up to date and supported best practice. Recruitment was seen as an essential part of keeping people safe whilst ensuring they were cared for and supported by staff of good character. Safe recruitment procedures were followed. Pre-employment checks had been completed and written references were validated. Disclosure and Barring Service (DBS) checks had been carried out for all staff. A DBS check allows employers to check whether the applicant has had any past convictions that may prevent them from working with vulnerable people.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People received their medicines safely and as prescribed. They were satisfied with the support they received and had no concerns. In a recent survey, everyone agreed they were involved with decisions around their care and medicines.

There had been various enhancements and improvements around medicines management following our inspection of June 2023. Medicine Champions had been introduced with an enhanced role. One champion who was enjoying their responsibilities stated, “It is my duty to ensure weekly medicine audits are conducted. This consists of recounting all the medication to make sure there are no mistakes, and it matches the medicine records. I also make sure everyone has enough medication in stock, all ointments and liquids are labelled with the date opened so it can be discarded when it needs to be. If staff have any concerns about medication, then they can come to me for advice.”

At the inspection of June 2023, we found no evidence that people had been harmed, however improvements were required to protect people through safe medicines management. During this assessment we found that improvements had been made and the provider was no longer in breach of our regulation. Policies, procedures, records and practices demonstrated medicines were managed safely. There had been no significant errors involving medicines in the last 12 months. Staff completed safe medicine administration training before they could support people with their medicines. The registered manager completed practical competency reviews with all staff to ensure best practice was being followed.