Eden Mansions Nursing Home

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

We found a friendly and welcoming atmosphere at the service. Discussions with staff and leaders, demonstrated a positive culture focused on person-centred care and continuous improvement. The provider’s website highlighted their vision for the future and quality of the care. Staff were positive about the culture and told us they worked together effectively as a team. Staff commented, “They (managers) have the best interests of residents. Their priority is to make sure they are taken care of and comfortable” and “One of the values of Cedar Care (provider) is dignity and respect.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People and relatives were positive about the management of the service. One relative told us, “The home is very well managed. If there are any issues, they have someone to fix them.” The registered manager was supported by a management team, who were responsible for various aspects of the service. They were organised and had systems in place to ensure staff understood their roles. Leaders were open, transparent and responsive throughout our assessment.

The service was large, and whilst people said they could share feedback with the Villa managers, most said they did not know the registered manager, whose office was in a separate building above the reception area. The registered manager undertook a daily walk around of the service to monitor the care provided and said they tried to introduce themselves to everyone. They were available if people wanted to meet with them.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistle-blowing policy which was accessible to staff. The registered manager told us staff could contact the operations manager directly if necessary. A Villa manager told us, “Staff all know I have an open-door policy, with any issues. I encourage them to use their observations and speak to me if they’re worried.”

Staff indicated leaders gave them the opportunity to provide feedback through various meetings, were approachable, and listened to any concerns. There was a staff forum, which the registered manager was purposely not involved, to allow staff the opportunity to speak freely.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

They had an equality, diversity and inclusion policy in place, as well as an anti-harassment and anti-bullying policy. This had been shared in a recent staff newsletter to highlight how they wanted everyone to feel they belonged. The policy promoted an environment free from discrimination. Staff feedback indicated they felt they were fairly treated, with support provided to grow and develop through training and qualifications.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders carried out various checks and audits and had recently completed an improvement plan. However, these audits did not identify or address some of the issues we found, including gaps in risk management and other records. Some care records were inconsistent, and there were occasional gaps in records to demonstrate care had been delivered as required. For example, for one person, staff said they had re-positioned them but had not yet recorded it, believing they had up to 4 hours to do so. The registered manager confirmed records should be updated as soon as possible and said they would address this immediately.

Oversight arrangements relating to other areas of the service were effective, and leaders acted on performance issues through meetings and communications.

Overall, the provider ensured notifications about specific incidents were submitted to CQC as required. Where we found one had not been submitted, the registered manager confirmed their understanding of the requirements and submitted this retrospectively.

The provider had not displayed their latest CQC rating on their website as required. We were informed this was due to a technical error, which was rectified immediately.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Feedback from partners, such as healthcare professionals, was positive and indicated staff worked with them effectively. They told us staff were keen to take part in any training and development they offered.

The registered manager told us they were focused on exploring better ways for people to engage with the community, such as visits from local religious groups. Trips within the community were arranged through use of a minibus, for example, a recent canal trip had taken place. We saw minutes of the wellbeing coordinator’s planning meeting, which encouraged links with the community.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. For example, the provider had registered with a national initiative supporting research in the care sector, with the added benefit of keeping up to date with emerging best practice. They enabled people to take part in studies, such as one relating to the impact of sounds and the environment

The provider continued to invest in the service to make ongoing improvements. They were working on the development of a new care planning system. They also had a refurbishment plan in progress, which aimed to improve the communal areas and create smaller lounges and activity areas. The provider was committed to environmentally sustainable approaches, and we sawsolar panels were being installed.