Edgemont 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 well led. People received a good standard of care because the management team led by example and had expectations about the standards of care people should receive. The vision, values and culture of the service were clearly communicated and understood by staff. The management team demonstrated a good understanding of the importance of effective quality assurance systems. There were processes in place to monitor quality and understand the experiences of people who lived at the home.

This service scored 64 (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.

The registered manager and deputy demonstrated effective leadership skills within their roles. Their knowledge and enthusiasm for the service, the people in their care and staff was evident. Equally the provider had a very ‘hands on’, active approach and presence within the service. Everyone was proud of the service and wanted it to be a positive experience and place for everyone. There was a clear commitment to providing person centred care and valuing people who lived at the home and the staff team. There was a holistic approach to care which captured the physical, emotional, and social needs of the people they supported. The provider told us, “Overall, we are very pleased with the way the home is working. The residents and their families appear happy and confident in the care they are receiving. The home is full, which we hope is testament to the care we offer.” One staff member told us, “I am very happy to work at Edgemont House, the manager is very professional, knowledgeable and a caring person. She has turned the home into a lovely place to live and work.”

The registered manager, deputy and provider had a visible presence within the service. They had the skills, knowledge, experience and credibility to lead effectively and were open and honest during this assessment. They were knowledgeable and interested in wider issues such as the recent changes to the CQC methodology and the implementation of the Single Assessment Framework.

Staff felt the registered manager and the deputy were always available and approachable. They were supported by the management team and felt confident to raise any concerns. The registered manager and deputy had an open-door policy and their daily presence meant people were seen every day and asked how they were. This approach had helped form relationships with people where they felt confident to express their views. Staff told us, “We have regular supervision and appraisals which are supportive”, “I feel very supported by my manager, and feel at ease to raise a concern, actions are taken when needed”, “The management are supportive and will always listen to staff if there was a concern or worry and will act on it”, “The directors visit at least weekly to monitor progress and support the managers and staff” and “I have full support given at all times especially for advice.”

Staff had access to whistleblowing and grievance policies and procedures. A complaints process outlined how people could raise concerns if they were unhappy. The registered manager’s approach to concerns was thorough, open and transparent. Where required, lessons were learnt and improvements were made.

Feedback from people and staff was gathered through planned meetings and surveys. There were regular opportunities to engage in house meetings, where choices were discussed, as well as being able to express opinions regarding staff, menus, activities, needs and home improvements.

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.

The registered manager and deputy had the knowledge and skills which complemented each other to ensure they had good oversight, and the service was running smoothly. The provider stated, “We have been supporting the managers with the process of change and improvement. The deputy has specific areas of responsibility and works closely with the registered manager to ensure the smooth, safe running of the home. They are currently being supported to undertake NVQ Level 5 in care which they are finding very rewarding.” One person told us, “I have seen an improvement in the leadership of the home. The manager and deputy have been working on improving systems and have been implementing the introduction of senior staff becoming ‘champions’ in certain areas. This is working well and releasing the manager to concentrate on the governance of the home. Care champions have improved the person-centred approach to individual’s care.”

At the last inspection, we identified a breach of regulations relating to good governance. At that time, we found systems did not always identify shortfalls or adequately monitor standards. At this assessment we found improvements had been made and the provider was no longer in breach of regulations. Systems were in place to monitor and evaluate services provided in the home. The registered manager and deputy reviewed concerns, incidents, accidents and notifications. This was to analyse and identify trends and risks to prevent recurrences and improve quality. Additional monthly audits were carried out for health and safety, infection control, the environment, care documentation, staffing levels, training, staff supervision and medication. Action plans were developed with any improvements or changes that were required.

People confirmed they were supported to attend health care appointments with staff or relatives.

The service was not registered to provide nursing support to people. The registered manager and the deputy demonstrated they worked effectively with a range of health professionals including dentists, occupational and speech and language therapists and specialists in mental health and dementia wellbeing.

Weekly rounds were completed by a GP and people could also attend their surgery in person. The service ensured everyone had prompt and effective access to primary care including preventative screening and vaccinations.

Feedback from health and social care professionals included, “The registered manager has always been forthcoming with information that I have asked to review. This includes care plans and risk assessments they have completed. All staff are very knowledgeable about the resident’s needs” and “Recently I have met with the manager and deputy to complete a very complex best interest decision meeting. Throughout the meeting, although challenging for all involved, they both remained professional, showed empathy, and were very knowledgeable about the person’s needs in order to support them effectively.”

The provider continued to work in partnership with other organisations to make sure they were following current best practice, promoted joined up working and shared new initiatives and ideas. They ensured they had effective working relationships with outside agencies such as the local authority commissioning and safeguarding teams and the CQC. Staff and leaders were open and transparent during this assessment process and engaged fully with the inspector.

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.