Edenbridge Manor Care Home

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 is the first assessment for this service following a change in the provider name. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

Systems were in place to keep people safe from abuse and harm. People received safe care from sufficient numbers of appropriately trained staff who knew them well and understood their risks and how best to support them. Staff were recruited safely to ensure they were suitable for their roles.

This service scored 75 (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.

The culture of the service was positive and one where learning was part of everyday practice. The peripatetic manager (A peripatetic manager isa manager who travels between services within the organisation them to provide leadership and support and act as a manager at a particular site where a registered manager is unavailable) and management team were available and approachable to staff, people and families. One person told us, “I go to the office, always someone there to help me.” A relative said, “Things have got better, communication is easier, I can go and see a senior or someone senior.”

Staff explained that the peripatetic manager and their colleagues helped them learn and improve practice when things went wrong. For example, lessons learnt were discussed in staff meetings, supervisions and daily handovers. One member of staff discussed the medicine errors that had occurred last year and said, “We went over to the electronic medicine administration record (eMAR) and things have really improved and we do twice daily checks of medicines, we all got training, and we do regular competency checks.”

The management team told us they investigated accidents/incidents events and had learnt from these. They gave an example of improvements they had made around people who experienced repeated falls, such as, sensor mats. They also demonstrated how they used root cause analysis to monitor urinary track and wound infections so as to prevent re-occurrences.

Safety concerns and events were thoroughly investigated and reported on, and lessons were learned to embed good practices. The provider told us they used learning from events/incidents at other services within the group to improve oversight of care and ensure people's continued safety. The service had a service improvement plan in place which detailed plans for ongoing improvements.

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, including when people moved between different services.

The management team worked with other health and social care professionals to make sure that people transitioned into the service smoothly. People moved on from the service only when they themselves chose to move, sometimes to be closer to loved ones or if the service could no longer meet their needs. The peripatetic manager told us they held meetings to discuss people’s changing support needs with district nurses and where appropriate the hospice team. Staff told us of ‘round table’ meetings that took place when there were concerns about needs being met. These meetings involved relatives and all necessary professionals and made sure that the best outcomes were achieved for people. People told us they were supported with transitions and moves. A person said, “The deputy manager came to see me in hospital, carried out an assessment there and then and I moved directly into the home. Could not have been easier.” Another person said, “Someone came to see me in East Surrey and questioned me on my needs." People’s support needs were recorded and updated within care plans which meant that changing needs could be tracked and addressed as soon as changes became apparent.

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.

There were organisational procedures for safeguarding people. These provided guidance about the action to take if staff had concerns about the welfare of people. Training records showed staff had completed safeguarding training. There was a system in place for recording safeguarding concerns which helped management have oversight over this. The peripatetic manager had appropriately made safeguarding referrals to the local authority when required.

Our observations found that people were comfortable with staff, we saw positive interactions, that assured us they felt safe and comfortable. People and their relatives told us that Edenbridge Manor was safe. One person said, "Very safe here, look after me.” Relatives' comments included, “I don’t have any worries, I visit regularly, and it is a nice atmosphere, I feel I can approach any of the staff for help or to answer any queries.”

Staff were aware of the signs of abuse and how to report safeguarding concerns. Staff confirmed that they had read the policies as part of their induction and refreshed at yearly safeguarding training. They were confident the management team would address any concerns regarding people’s safety and well-being and make the required referrals to the local authority. Staff had a good knowledge of whistleblowing procedures and would use them if they felt their concerns had been ignored.

One staff member said," I would discuss with my team and take it to management, we get training, the training is very good, informative.” Another said, "Direct communication with my team, inform the senior, and they will communicate with manager and record on fusion."

Staff introduced us to people and were very knowledgeable about them. People were observed to approach staff for assistance and staff responded in a kind and respectful manner. Staff walked with people to direct them in a non-controlling manner ensuring that the person was comfortable being directed, either to their room or to communal areas.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff were able to tell us about people and the risks associated with their care. They told us how they supported them safely. This included pressure area management, safe mobility and what to do when people become distressed. Staff told us, “All residents have care plans and risk assessments which we read, we have daily meetings to discuss any changes, I think we have a good grasp of risk.” We discussed with staff, certain people who had either bruising or dressings on and they were able to discuss how they occurred, what actions had been put into place and any potential risks. Staff told us that additional checks were in place for people at risk of falls. These included sensor mats, location checks, appropriate footwear checks, and ensuring people had the appropriate walking aids and were wearing their glasses if needed.

We spent time with people and staff both in communal areas and in peoples' bedrooms. People who were at risk from pressure damage had air flow mattresses and these were set correctly as per manufacturers guidance against people’s weight. Staff recorded these checks on the persons’ care documentation. People who were at risk from falls, had sensor mats that alerted staff the person was up and at risk. Call bells were in peoples' rooms, and there were risk assessments in place for those who couldn't' use a call bell and we saw that staff checked them regularly. We observed equipment being used appropriately to reduce people’s individual risks, such as walking aids. Corridors were free from obstruction, allowing people to walk safely if they choose to. Care plans and risk assessments included clear guidance for staff on how to minimise risks, for example, for people at risk of dehydration and malnutrition, there was evidence of close monitoring and included the actions taken by staff of fortifying food or use of supplements.
The management team undertook an analysis of incidents and accidents and referrals were made for additional support where required, for example, in reach team, falls team, and GP involvement.
Staff received training in areas of potential risk such as moving and handling, first aid and health and safety. All staff received fire training and undertook night and day evacuations to ensure all staff have confidence in the event of fire to manage people safely. Personal Emergency Evacuation Plans (PEEPS) had been completed for each person. PEEPS give staff or the emergency services detailed instructions about the level of support a person would require in an emergency such as a fire evacuation.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Our observations showed us that staff were visible and available to support people’s requests for help and take the time to sit with people, to assist them with food and drink if necessary. People received timely care, and call bells were answered promptly.

The staffing levels were based on peoples’ needs and regularly reviewed. We looked at 3 months of rotas and the staffing levels were consistent supported by relief staff to cover vacant positions, sickness and holidays.

Staff numbers and the deployment of staff had ensured people’s needs were met in a way that met their preferences. Care delivery was supported by records that evidenced that people’s care needs were being met.

Staff were recruited safely. The provider undertook checks on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least two references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Our observations showed us that staff were visible and available to support people’s requests for help and take the time to sit with people, to assist them with food and drink if necessary. People received timely care, and call bells were answered promptly.

The staffing levels were based on peoples’ needs and regularly reviewed. We looked at 3 months of rotas and the staffing levels were consistent supported by relief staff to cover vacant positions, sickness and holidays.

Staff numbers and the deployment of staff had ensured people’s needs were met in a way that met their preferences. Care delivery was supported by records that evidenced that people’s care needs were being met.

Staff were recruited safely. The provider undertook checks on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least two references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people.

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.

People told us, “The housekeeping here is really good, they polish and make sure my room is clean, my bathroom is kept spotless,” and “They (housekeepers) do us proud, very clean and never a smell.” Visitors told us the home was always clean and well maintained. “Lovely environment, it’s very clean and always smells fresh.” Another visitor said, "Well-kept, clean and welcoming."

Staff told us they are well resourced for cleaning and infection control. One said, “Personal protective equipment (PPE) is not an issue, we have enough and also cleaning products and equipment.”

The home provided people with a clean, and well-maintained environment. People’s rooms were cleaned regularly by housekeeping staff and people commented positively, with no-one reporting any problems with the standard of cleanliness of the environment and equipment.

We saw housekeeping staff undertaking cleaning in all parts of the home. Our observation of the environment raised no concerns about safety or cleanliness. People’s laundry was managed well, and the laundry room was clean and well organised, and people were well dressed.

The housekeeping staff understood their role and followed appropriate procedures to keep the home clean. All staff understood their responsibility to reduce the risk of infection and followed infection control guidance. There were posters and training to assist staff in keeping up to date with any changes to infection control measures. Audits were completed by the infection control lead to ensure compliance with the procedures and policies of the home. Staff were trained in the use of personal protective equipment (PPE) and of the importance of good hygiene practice. The manager told us they ensured staff continued to follow Public Health England guidance to reduce the risk of COVID-19. People had received COVID-19 booster injections.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff supported and involved people to manage their medicines and followed best practice for administering medicines. Staff documented medicines clearly in care plans and made them available when people moved between healthcare settings.

Not everyone could share their experiences regarding medication, but one person said, “They support me, I do keep some of my own, but staff order them for me,” and “It’s a relief not to worry about drugs, makes my life easier and less stressful.” One family member we spoke with said, “We are kept informed of any changes, especially if the GP changes the medication, I have no concerns at all.”

Due to a large number of medicine errors in 2024, the organisation made a decision to change to an Electronic Medication Administration Record (eMAR). This has reduced the amount of medicine errors. Staff talked openly of how they had improved medicines by introducing twice daily medicine counts and further training. Medicine givers have all received extra training and support to give medicines safely.

Staff who gave medicines had the relevant knowledge, training and competency that ensured medicines were handled safely. We observed staff giving medicines safely and that they were recorded accurately. Risk assessments were in place for certain medicines. All discrepancies and medicine errors were recorded and investigated and action taken as required. Daily and monthly audits were carried out, and any shortfalls were addressed. Protocols for 'as required' (PRN) medicines such as pain relief medicines were in place however, they were very generic and lacked personalisation. This was being addressed by the clinical lead.