Edingley Lodge 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. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 78 (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.

Accidents and incidents were reported, thoroughly investigated and action taken to reduce any risks. External professionals were appropriately involved, for example contacting the occupational therapist when a pattern of a person experiencing mobility issues was found through review of incidents. Matters were appropriately reported to external agencies including the local authority and CQC.

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.

When people moved into the service, or were coming to the home for respite care, the management team carried out a detailed assessment of their needs. The registered manager told us, “I follow Barchester’s safe admission policy because I have responsibility to make sure admission is safe and we can safely meet that person’s needs and that person will also be able to join with the current resident group, it is so important. I start with a pre-admission assessment, myself or the deputy go out to the community to do this [with the person]. Then we go to GP surgery to ask for a patient summary, so we have got details of medical history, what needs to be in place and what sort of training we need. The assessment involves family members as well so they will have input, we take points from them as well.” This was reviewed regularly including when people returned for future respite visits to ensure the information about people’s care and support was current and reflected their needs. This approach was confirmed by people and family members. One relative said, “[Registered manager] came to [relatives] house to talk about their needs and medication. People were provided with a comprehensive service user guide, so they knew what to expect when moving to the home. People were also encouraged to visit the home prior to staying, whether short or long term. On the day of our assessment a carers organisation who support unpaid carers of all ages and the people they look after had been invited in for afternoon tea to look around the home and chat to residents to get their views.

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.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to make decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of Liberty Safeguard (DoLS) was applied for through the relevant local authority.

Staff had received safeguarding training and were all knowledgeable about what action to take if they had any safeguarding concerns, including how to escalate to other agencies, and indicators of abuse to look out for.

Staff understood what made people feel safe and gave examples which included the positioning of equipment. Relatives also told us what staff did to make their loved one feel safe both physically and emotionally. One relative said, “[Relative] is supported physically, but when they feel vulnerable the staff are there. In the evening, if [relative] is anxious, the staff bring [relative] with them on their break, so they’re not always on their own."

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.

We saw people were supported to do the things that mattered to them which included outings and activities which were risk assessed. For people who may experience barriers to communication, for example: visual impairment, care plans emphasised people’s preferred means of communication to support their understanding and ability to make informed choices by providing information in a way that they understood.

Risks were assessed and mitigation in place which was recorded in people’s care plans to keep people safe whilst promoting them doing things they wished to do.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The maintenance team worked closely with staff, the management team and residents to ensure the internal and external environment was safe and well maintained. One of the maintenance personnel told us, “We do go above and beyond but we make sure everything is up and running and good, they [provider] will spend money, and they do like you to keep things up to standard. I would be happy for a relative to live here.”

We saw health and safety checks were consistently carried out, there were appropriate evacuation plans in place for each person in the case of an emergency, and technology was used to support people to remain safe in the home. For example, the use of sensor mats to alert staff if someone got out of bed if they were at risk of trips or falls.

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.

Staff told us they felt they had the right training to effectively carry out their role; they received regular supervision with the management team and were encouraged in their professional development. We saw the registered manager kept track of the training staff had received to ensure it was completed and any refresher training was completed as required.

The registered manager and staff team told us how they work together using a “whole team approach” which fostered people in different roles working together to meet people’s care needs safely. One staff member said, “It’s a whole home approach, if the staff all work together [for example] at resident’s mealtimes it all flows well. Communication between departments is good as well, we have a fantastic care team.”

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.

All communal and private spaces in the home were clean and tidy. There was personal protective equipment, for example, gloves and aprons, available and all staff were trained to understand infection prevention and control. The head housekeeper was the infection control champion and showed the inspection team the cleaning schedules as well as a guide for staff which contained information on cleaning products and best practice.

People were well presented and supported appropriately to maintain their personal hygiene. Feedback from people, visitors and relatives regarding the cleanliness of the home was positive. One visitor said, “I’m very impressed by the cleanliness and appearance of the home.”

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences.

We found protocols for ‘as required’ medicines, for example paracetamol, were in place but staff did not consistently record the outcomes of when this medicine had been taken. The management team had already identified this issue, and we saw this was being addressed with staff and the policy of the month for staff to review was the medicines policy to improve staff practice.

We also noted some ‘as required’ medicines had a variable dose, the deputy advised this was being addressed already, which was evidenced, so there was clear guidance for staff on the exact dose people should be given.

Medicines and creams were all in date and appropriately labelled when opened. Items were all stored appropriately. There were no gaps in medication administration records, including topical medicines, and we saw where people used medicated patches, they had supporting body map documentation in place to ensure effective rotation of patch application sites.

Staff had all received appropriate training and competency assessments to administer medicines.