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. At our last assessment we rated this key question Good. At this assessment the rating has remained Good.This meant people were safe and protected from avoidable harm.

This service scored 63 (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 provider had a system in place to document all incidents and accidents and to learn lessons. All incidents were reported on an electronic system which set automatic prompts to the manager to ensure actions were taken to learn lessons when things went wrong. Incidents including falls were documented on the electronic system, and this information was collated and shared with staff within team and governance meetings to ensure learning was shared. When people fell there were systems in place to ensure that referrals were completed and care plans were updated.

The provider identified that risks relating to skin integrity were being managed poorly and, in some cases, resulted in harm, and lessons learn to prevent this happening in the future. We have reported this within the ‘Involving people to manage risks’ quality statement.

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.

Systems were in place to ensure that when people moved between services information was made available to them. People received continuity of care through a stable staff team. When people needed referrals to other organisations and healthcare professionals staff supported them with this. For example, when people were at risk of choking referrals were made to the speech and language therapists (SaLT). Guidance from SaLT was translated into care plans to provide clear information for staff to follow to reduce the risks of choking.

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 systems and processes in place to document and report safeguarding concerns. When a safeguarding concern occurred staff documented this on the electronic system, which then alerted the manager that they needed to review the concern. The electronic system prompted the manager to complete actions, including reporting the concern to the local authority safeguarding team and the CQC. Staff had received training in safeguarding and understood their responsibilities in relation to sharing safeguarding concerns.

Where applicable, Deprivation of Liberty Safeguards (DoLS) had been completed and notifications had been submitted to the CQC. DoLS are important human rights safeguards; they aim to ensure that such deprivation of liberty only happens when it is necessary, proportionate and in the person’s best interests.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people had not always been mitigated. For example, one person was at risk of their skin breaking down and then sustained a pressure injury. Their care plan stated that they needed support to re-position every 3 hours, however daily records did not confirm this was happening. Another person’s care plan stated they had ‘red marks’ identified on their skin, and were at very high risk of skin breakdown. Their care plan had not been reviewed after this, and there was no information to detail if the issue had been addressed. Their care plan stated the person should be encouraged to reposition ‘regularly’ but did not specify how frequently this should be. When we raised this with the provider, they organised re-training for staff to inform them how to keep people’s skin healthy and spoke with staff about the documentation of re-positioning people.

Other risks to people had been assessed and mitigated where possible. There was guidance within care plans on how to support people at risk of choking. We observed staff using safe manual handling techniques to support people to transfer safely.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider completed a suite of checks and audits to review the safety of the environment, which had mostly been completed. However, some checks had not been completed regularly for example checks to see if the water was running at the right temperature were not completed since October 2025. In January 2026 it was identified that some water outlets were running too hot. Whilst action was taken to address this, there was a risk that between October 2025 and January 2026 people were exposed of increased risk of scolding. Once the provider was aware, they took action to address this to ensure that the temperature of the water was addressed. Checks on profiling beds had not been completed in December 2025 and January 2026. We raise this with the provider who took action to address this. Other checks were in place, such as recent fire drills completed, hoists had been checked and audited and checks on window restrictors were completed regularly.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support, supervision and development. Staff mostly worked well together to provide safe care that met people’s individual needs.

We observed, and people, relatives and staff told us that there were not always enough staff on duty. Staff told us, “I do find staffing is an issue on this floor.” Staff told us there were points in the day, particularly in the morning when people used their call bells more frequently, and staff were not always able to respond to them. Staff told us, “We can’t always answer and it’s stressful.” We raised this with the provider, and whilst a recent dependency tool had been completed, other staff vacancies impacted the morning routine. Although we observed a wide range of activities, some people fed back that activities were impacting due to staffing. A person told us, “More often than not activities are cancelled without people being made aware or changed without explanation. There is not always activity staff present which sometimes limits amount of stimulation, including access to the community. Sometimes activities cancelled when not many people attend.” Following our inspection, an additional care staff was added to the rota to support with morning care, and two new host staff began working at the service to support with morning mealtimes.

Interactions we observed with staff and people were positive. Staff showed a good understanding of how to support people living with dementia, including how to support them when they were distressed.

Staff were recruited safely. The provider ensured that checks on new staff were completed, these included Disclosure and Barring Service checks (DBS). A DBS check is a criminal record check in England and Wales used by employers to make safer recruitment decisions.

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.

We observed the service to be clean, and free from malodour. Staff responsible for cleaning the service told us they had enough time to do so. Staff told us, “Yes I get time to engage and have a chat to people. There is a cleaner for each floor and somebody in the laundry. Yes we are able to get around and keep everywhere clean.”

All staff had completed training in infection prevention and control. The manager completed several checks on the service weekly to ensure that it was clean, and to mitigate the risks of infection where possible. A relative told us, “It’s clean, we’ve never had issues.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Some people were prescribed time sensitive medications. We found that these medicines were not always administered at the required time. Delaying such medications, could cause people to experience worsening tremors, increased rigidity, loss of balance, confusion, agitation, and difficulty communicating. Some people were prescribed medicines on an ‘as and when’ basis such as painkillers. Where these were in place guidance on when to take the medication was not sufficiently detailed. The provider was aware ‘as and when’ guidance needed to be improved and had a plan in place to update these.

Some people were prescribed pain patches. Pain patches are applied to the skin and release a measured dose of pain relief through the skin. Pain patches require consistent rotation, precise recording, and specific skin care to avoid toxicity or reduced efficacy. We found that staff were only documenting the site of the last pain patch application, however the manufacturers guidelines state that the patch should not be applied to the same site for 3 weeks. We raised this with the provider who assured us they would address this.