Edenbridge Manor Care 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. This is the first assessment for this service following a change of provider name. 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.

The culture of the service was positive and one where learning was part of every day practice. The management team was available and approachable for staff, people and families. The staff team felt valued and well supported in their roles, and able to ask anything or make suggestions for improvement of the service. There were good governance systems in place to monitor the quality of care, and to consistently learn and improve outcomes for people.

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 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.
Staff spoke to us about the vision and culture of the service. Staff said that the management team were approachable and keen to listen, and that they feel well supported. They said that things had improved and felt the home was definitely going in a good direction. The peripatetic manager and staff understood and supported people’s and staffs’ cultural and spiritual needs. People were treated equally, and their individual needs were met in line with their preferences. The management team knew people well and also worked alongside staff to support and promote good practice. All the staff were positive and proud of the care delivered to people who lived at Edenbridge Manor.

Feedback from staff was consistently positive and enthusiastic when we spoke with them. The service aimed to give people consistently good care and staff worked together to try and achieve this. Individual staff supervision and group team meetings were used by the provider to remind staff about their organisations underlying core values and principles.

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.

Staff said about the in-house management team, that they are, “Visible and are happy to help and advise on the floors,” “They share with us and our residents about changes, and they have time to listen.”

The senior management team were committed to improvement and were open and transparent regarding the improvements made and those that were on going. We were told that the focus of the service was to ensure people were safe and happy, and that any learning was taken forward positively.

There were systems and processes in place to support staff development and progression within their roles. They talked of how they were supported to gain qualifications and to consider extending their role, for example to become Care home assistant practitioners (CHAPS). Senior care staff were supported to become medicine givers and received support and training. Regular supervisions, spot checks, competencies and values-based supervisions took place. The provider’s senior management visited the home regularly and provided support and supervision to the peripatetic manager, who confirmed she attended organisational manager meetings which enabled learning across the organisation to be shared and relevant lessons learnt implemented within the home. The provider supported staff to attend external training, conferences and meet with other providers and managers to network through various forums.

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

Staff told us that felt able to raise concerns. One staff member said, “I feel that I could voice any concern, we can do it anonymously if we want to,” and “We are all reminded at meetings and supervisions of safeguarding procedures, raising concerns and whistleblowing options.”

The provider and peripatetic manager understood their responsibilities under the duty of candour. The Duty of Candour is to be open and honest when untoward events occur.

We have received notifications as required. During our assessment we found that the management team were open and transparent. They admitted when things had gone wrong and demonstrated how they had used these to make improvements. They told us of the work they had done to improve and meet breaches of regulation from the last inspection under a different provider name.

Staff were supported and enabled to voice their views and concerns. They were aware of the whistle blowing policy but felt that they could raise them and be listened to. The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance. People and their relatives confirmed they knew how to complain, and a copy of the complaints policy was available in the home and on the service website. Relatives told us; they would make a complaint if they needed to but would talk to staff first. A record of complaints was held in the service. These included the information on the complaint and how this was responded to. We saw complaints had been responded to and actions taken as necessary.

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.

Mental health and wellbeing of staff were regularly discussed since the change of management to ensure staff felt supported through changes. The home was proud to be inclusive and supported both staff and people that used the service. The peripatetic manager said the staff team was multicultural and everyone was respectful of each other.

Staff felt they were treated as individuals and their needs were taken into consideration, such as shift times being re-arranged to fit in with family commitments if required.

The provider had procedures in place to promote staff well-being and worked to provide flexible working conditions if required. There were robust measures in place to monitor, maintain and promote good mental well-being across the staff group. There was a formal recruitment process and equality, diversity and inclusion policy in place to guide equitable and fair recruitment and selection procedures. Staff were encouraged to undertake training in equality and diversity.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Quality assurance systems were in place and used effectively to improve the service. The management team had worked hard to ensure there was robust oversight and effective governance at the service. There were computerised systems and processes to assess, monitor and improve the quality and safety of the service provided. Governance meetings were held regularly and minuted. These were used to monitor effectively and pick up trends/concerns early.

Staff told us about their duties and responsibilities, they told us how they managed risk and reported concerns to management. Managers and staff understood their roles, and were clear about quality performance, risks and regulatory requirements. There were checks and audits in place to monitor quality and safety. Action was taken when audits identified areas for improvement.

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.

This included using services such as advocates, physiotherapists, chiropodists and hairdressers. One external stakeholder told us, “I enjoy working with this service, lovely place to come to, staff are polite, I have no issues with this home, a manager or a senior will always greet me, to answer any queries and to give me accurate update on my clients.”

External performers were booked to provide entertainment to people, and trips out happened regularly with a volunteer driver from another home in the organisation.

Trips were arranged to match with people’s hobbies and interests, such as gardening, parks, feeding ducks, and local places of interest. At resident meetings activities were discussed and people’s comments noted and taken forward.

Staff said they have good relationships with other health professionals and one staff told us, “We work together to get good outcomes for people.” The registered manager said that people were part of their local community. They said, “We are arranging trips out and inviting people in such as local schools and churches.” The registered manager had recently arranged for one person to be visited by a religious representative. They worked closely with external professionals and told us they would be confident to contact someone directly without hesitation

Health professionals told us that they have a good relationship with the service and staff work with them in a professional and knowledgeable way.

The registered manager and provider were proactive in building relationships with other organisations and into the local community to improve outcomes for people. They told us how they had contacted the local council about using their large garden for allotments for local people which would allow people who live there to be involved if they chose to. They had close links with the local authority and utilised any additional training opportunities when they were offered.

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.
People and their relatives had opportunities to feedback their views about the service and quality of the care they received. People and relatives all described the staff and management of the service as open and approachable. Staff supported people to give feedback and opportunities which they had to drive improvements and encourage learning from any incidents which occurred. The provider and registered manager had oversight of accidents and incidents. Trends and patterns were identified and addressed. We saw example of lessons learnt following incidents which occurred within the service. For example, introduction where appropriate of crash mats and sensor alarms. Reflective meetings were held with staff to give opportunities to discuss development points to encourage improvement in practice. Learning was, where appropriate, also shared across the providers other services. The registered manager encouraged staff to speak up about positive ideas.