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. At our last assessment we rated this key question Good. At this assessment the rating has remained the same. 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 71 (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.

There was a positive culture within the service which was demonstrated consistently from the management team throughout all the staff. Staff consistently told us they were happy working at the service, that they had shared values and visions for the service and worked together to provide a positive environment for people to live in.

People gave consistently good feedback about the service. One person told us proudly about a club they helped start, which helped to bring other men together regularly with shared interests. They told us, “For people with dementia this really helps them to communicate and open up.” They also told us that their opportunity to have activities specific to them were really important to them.

Some people had specific cultural needs, which included how much intervention they wanted with their care and support. This was documented clearly within the care plan and known by staff.

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.

There was a clear structure at the service and each staff member understood their roles and responsibilities. Staff gave positive feedback about the management. Comments included; “[The manager] is just amazing with all the staff and even better with the residents,” and “[Regional director] was brilliant. I don’t know the new one much but he seems very good. [Regional support manager] comes frequently and she’s very good with all the residents. People told us the management were responsive to issues and addressed them. One person told us, “Managers are approachable, there’s an open-door policy.” The manager told us, “A happy team is a happy home for all the residents.”

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

Staff told us that they were able to share their voice and that if they had concerns they would be addressed. Staff told us that managers at all levels were approachable, and they could share any concerns with them. We observed staff at ease with managers at all levels. Staff we spoke with were able to tell us how they could raise concerns internally and externally.

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.

All the staff we spoke with were positive about working at Edenbridge Manor Care Home. Staff told us they received good support from managers at all levels, and felt they were treated fairly. One staff member told us, “The manager is lovely. She has helped me recently, supported me I cannot fault her. She tries to bring us together as one team. She makes sure everyone is working together and helping each other out.”

Diversity was celebrated within the service, including different cultures. During team meetings the manager brought snacks in from different parts of the world as a topic of conversation and interest for staff to engage and bond. There was a room available for staff to use for prayers. Consideration had been made for staff observing Ramadan in relation to their shift patterns and breaks they needed.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Care plans and risk assessments did not always contain the necessary information to inform staff how to support people safely. For example, one person’s care plan stated they needed support to re-position ‘regularly’ but did not define how frequently this should be. This increased the risk that people were not supported to re-position when required. Another person’s care plan stated that they mobilised using a hoist and sara steady, but then also stated that the person stayed in bed all the time. Although audits had been completed on care plans and risk assessments these inconsistencies were not picked up and rectified. A person had developed a pressure sore and other people had areas which were sore and red. The lack of effective oversight contributed to the risk of skin breakdown not being addressed and people came to harm.

Checks and audits on care plans failed to identify where guidance was missing or not accurate. Care plans and risk assessments did not always contain accurate consistent information about people. For example, one person’s care plan stated that they were to use ‘homely remedies’ if they were to become constipated and also stated that they were prescribed medication for constipation. A homely remedy is a medicine used to treat minor ailments. They are purchased over the counter and do not need to be prescribed. Other concerns with medicines management including time sensitive medicines not being administered as required had not been identified. ‘As and when’ guidance was not clear and specific to inform staff maximum dosage people were able to have in a 24 hour period. Risks to constipation had not been managed consistently well. The inconsistencies in medicines oversight meant people were placed at risk of avoidable harm.

Other checks and audits on the service did identify areas for improvement and ensure that actions were taken to address these.

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.

Staff and the managers worked with healthcare professionals to provide joined up care for people. For example, when people’s needs changed staff organised for them to be reviewed by the falls team, SaLT, and people had access to the GP and district nurse.

People were involved in the local community. The service had a minibus which enabled people to go out. Managers organised for local schools to attend the service, and people told us that they enjoyed showing the children their activities and interests.

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.

The manager and senior managers had monthly meetings which reviewed most areas of the service. This included reviewing to ensure all staff has their training in date, checking on audits completed and following up on falls to ensure action was taken to make referrals. Actions included follow ups after falls had occurred, and referrals to SaLT following choking incidents. During the inspection leaders were open to issues raised and ensured that lessons were learnt and improvements and training were implemented when highlighted.