Edgewater

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. This was the first inspection for this newly registered service. This key question has been rated 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 61 (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. Staff spoke very highly of the registered manager and deputy manager; they spoke of being trusted and supported to deliver care and support. Staff and management understood the importance of listening to the views of people and their relatives about the service. The provider worked with the staff team to build open and transparent relationships. People and their relatives had been provided with clear information on how to raise suggestions and concerns about the service.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. The registered and clinical nurse manager were both visible at Edgewater and transparent with us throughout the assessment timeframe. Staff spoke highly of the management team and how their skill mix complimented each other and benefited the team. Despite the issues identified in this assessment with medicines, the leaders were open and honest and had the experience and knowledge to lead effectively with integrity to make the improvements required.

Staff told us they knew about the providers whistleblowing policy and knew how to raise concerns. Staff were aware they could report any concerns directly to the Care Quality Commission and the local safeguarding team. There was a whistle blowing policy in place and staff were informed about this as part of their induction. Staff could access the policy if needed at any time. People had information provided to them, this allowed them to know how to raise a concern and their right to speak up. People and their loved ones told us they knew how and where to raise any issues or complaints. Comments included, “I speak to deputy who is good. Give me all the updates. I can have access to [name] care plan and if I need to speak about any concerns I can,” “I have raised one concern and feel like they listened to me and some changes did happen” and “They hold a meeting every couple of months for family and I can’t go because of the time to travel there but I know if I had any issues I could go.”

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. Staff had all received equality training, and most felt they were treated fairly and equally. Staff had made requests and held discussions identifying areas of work where they required additional support or adjustments. The registered manager and deputy manager told us they would always endeavour to provide support where required.

The provider did not have sufficient systems to assess, monitor and improve the quality and safety within the service. We found medicines audits were completed by leaders but failed to identify gaps and actions were not completed following these audits. For example, shortfalls identified with medicines and up to date care records. During the assessment the registered manager provided evidence they were addressing the concerns highlighted in this assessment.

The provider understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. Partners we spoke with confirmed the provider worked with them to develop and improve the care for people.

The provider was focused on continuous learning, innovation and improvement. 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. The registered manager understood the needs of people living at the home, including individual circumstances. Staff we spoke with confirmed this and told us they were regularly asked for feedback on what could be done better.