Edward House

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 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 requires improvement. At this assessment, the rating has remained requires improvement. This meant there were widespread shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider remained in breach of Regulation 17 Good Governance at this inspection.

This service scored 57 (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 did not have a clear shared vision, strategy and culture for the management and staff team to ensure each individual person was at the centre of their support when decisions about their lives were being made. Closed cultures were not an active discussion, for example during team meetings, so if they started to develop, they might not be quickly identified due to the lack of the team’s awareness of this issue.

Whilst there was no evidence of an organisational shared direction and culture staff did have views on this. One staff member told us, “We’re all here for the same reason, that’s the residents.”

The service had experienced changes in the management team, but the current registered manager and deputy manager were open and honest about issues discussed with the inspection team.

The registered manager adopted an open-door policy, and we observed staff popping in and out of the office throughout the inspection to speak with the management team.

Feedback about the approachability and compassion of the leadership team including senior support workers was mixed and we also considered feedback from whistle-blowers as part of this. Some staff felt the leadership team were inclusive and supportive and they felt “part of a little family.” However, some feedback included concerns about the approachability and attitude of the leadership team. These concerns were discussed in full with the registered manager, as well as consideration of closed cultures, as part of the inspection feedback for them to reflect upon and address.

The inspector spoke with the deputy manager who was keen to develop in her role and build on the skills she needed to effectively lead the team and focus on how they could enable people to live a good life as part of their community.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did listen to concerns about safety but lessons were not always learnt to continually identify and embed good practice.

There were no processes or systems in place when incidents had occurred to review what had happened and prevent re-occurrence. For example, the data for incidents and accidents was collated but there was no analysis to identify themes and trends to put measures in place to avoid incidents recurring and reduce the risk of harm to people.

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.

There was an appropriate equality, diversity and inclusion policy in place. We did not receive any concerns from staff about being treated inequitably.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did listen to concerns about safety but lessons were not always learnt to continually identify and embed good practice.

There were no processes or systems in place when incidents had occurred to review what had happened and prevent re-occurrence. For example, the data for incidents and accidents was collated but there was no analysis to identify themes and trends to put measures in place to avoid incidents recurring and reduce the risk of harm to people.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

There was not clear and effective governance, management, and accountability arrangements. For example, we reviewed quality assurance questionnaires and noted it was unclear if actions had been taken. People also told us they had not been advised of the outcomes.

Staff did not have clear direction about who to contact for out of hours support which was unsafe practice and also placed unnecessary pressure on the management team who told us they were “on-call 24 hours a day”.

Issues identified at the last inspection had not all been addressed and there was no service improvement plan in place to log issues, identify required actions and review to ensure actions were completed.

We discussed all of the issues identified regarding learning and improvement with the registered manager. The management team were very receptive to feedback and communicated that they were keen to make changes and improvements.

The provider had recently introduced a digital system for recording daily records, care plans and monitoring activity, for example, recording fluid intake, to support with availability, integrity and confidentiality of data.