Edgewater

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This was the first inspection for this newly registered service. This key question has been rated requires improvement.

This meant some aspects of the service were not always safe and there was an increased risk people could be harmed.

The provider was in breach of legal requirements in relation medicines management.

This service scored 59 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. However, we did find concerns in relation to medicines which had not been highlighted prior to this assessment. People, and their loved ones told us staff provided safe care. When incidents occurred, relatives were kept up to date and informed of actions taken to mitigate further risk. One persons loved one told us, “The nurses keep me informed of any changes, especially in the medications and I have no issues around communication with nurses, or manager.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care and staff supported people. Staff demonstrated they knew people well and understood their needs. A health professional we spoke with told us they worked with the provider to meet people’s needs, and they were always open and worked in collaboration. Referrals were in place for services such as speech and language therapy (SALT), occupational therapy and GPs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider did not always work well with people to understand and manage risks. The care staff did provide to meet people’s needs was safe, supportive and enabled people to do the things that mattered to them. Whilst risks to people’s personal safety had been assessed some care plans did not always record the care needed to minimise these risks and keep people safe. For example, risk assessments and care plans in place where not always detailed around some preferences and specific needs in relation to medicines.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The environment and equipment were kept in good condition, ensuring health and safety standards were consistently maintained. There was an up-to-date fire assessment for the service and each person had a Personal Emergency Evacuation Plan (PEEP) which set out detailed instructions about the level of support a person would require to evacuate the building in the event of an emergency. The fire alarm system was tested, and regular fire drills took place so staff could practice evacuation procedures. We saw valid certificates for legionella, gas safety, electrical safety and portable appliance tests. Staff received training, in health and safety, fire, first aid and moving and handling, and fire evacuations.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development opportunities. They worked well together to provide safe care meeting people’s individual needs. Staff recruitment processes were in place with relevant checks of staff’s employment history, character, right to work, and checks with the disclosure and barring service (DBS). Staff we spoke with were very committed and passionate about the work they did at Edgewater.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Shared areas of the home as well as people’s own rooms were clean and tidy. The home was clutter free. Staff wore personal protective equipment (PPE) appropriate to their tasks. People were supported to maintain good hygiene. Staff knew about infection prevention procedures which they followed to protect people from risk.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. The medicines administration records showed routine medicines were signed for and stock levels showed they had been given as prescribed. However, when people were prescribed medicated patches, staff were not always recording the site of the location of the patch, therefore there was a risk the patch was not applied in line with the manufacturer’s instructions and people could suffer unnecessary side effects. When people had their medicines covertly, hidden in food or drink, there was not always information to support staff to administer the medicines safely. When the information was available, staff were not always following the information to administer the medicines, therefore there was a risk they were not being given safely. When people needed blood tests to determine if a medicine was needed, the result of the test was not always recorded. Staff were not always following the person centred care plan to ensure the blood tests were completed at the required frequency each day. This meant there was a risk they might not get the medicine they needed. When people had their medicines via a feeding tube, there was not always information to support staff to safely administer the medicines. When people were prescribed ‘when required’ medicines, there was not always person centred information to support staff to know when to give the medicine. In addition, when people were prescribed a variable dose for example 1 or 2 tablets, there was not always information to support staff to know which dose to give, so there was a risk people might not get their medicines when they needed them or at the most appropriate dose. Medicines audits were not always effective in identifying medicines related issues. Proposed actions from these audits were not always completed. This was a breach of Regulation 12, medicines.