Edwardian 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 requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service. The provider had not always ensured their systems were effective or ensured oversight of quality, safeguarding, environmental safety, effective care planning and management of risks. People were not always being protected by MCA.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service lacked a clear vision and culture centred on transparency and human rights. The registered manager did not uphold individuals’ rights, they failed to ensure staff were always working within the principles of the MCA which meant the culture of the service was not person centred. Safeguarding concerns were often overlooked.

Staff were unaware of any organisational values and meeting minutes did not demonstrate conversations between management and staff in relation to organisational vision and how care and support should be delivered to people.

Several staff raised concerns about the negative workplace culture at the service, and inadequate treatment by leadership, affecting their wellbeing. In response to feedback, the provider hired an external Human Resource manager to support staff. Staff confirmed meetings had been organised with this resource enabling them to voice their concerns and help resolve any conflicts.

The service did not demonstrate they had capable leadership with the right skills and knowledge as we identified breaches of the legal regulations. This meant leaders had not always identified and taken action to ensure people received care that was in line with legal requirements.

The registered manager lacked an understanding of regulations in respect of staff recruitment requirements and did not ensure robust checks were made before staff were employed to support people.

Mixed feedback was received about the capability of the registered manager. Some staff felt unfairly treated by management due to culture issues. However, other staff told us they had no concerns with the management team, stating they are approachable, listen to staff concerns and make efforts to improve when required.

The registered manager felt supported by the provider.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not have good governance systems in place. They did not act on the best information about risk, performance, and outcomes.

Management oversight was lacking in respect of staff training. We could not be assured that staff had been trained to provide safe and effective care. We received version 4 of the training matrix, but 4 members of staff were still showing as carers when they had been promoted to senior carers. For example, the training matrix provided at the start of our assessment did not show whether staff had completed medication administration training.

The quality assurance systems at the service included regular audits. These included medicine, accident and incident, health and safety, kitchen, IPC, personnel files, care records and finance. There were gaps in the system and the provider audits had failed to identify the concerns we found relating to medicine records, care planning and levels of staff currently deployed.

Mental capacity assessments were inaccurate and not detailed. Audits of incidents and accidents were taking place; however, some incidents were not described in full, and some met the threshold for a safeguarding referral. Other members of staff were delegated to conduct various checks, including health and safety and infection prevention control audits but there was no further monitoring or oversight by the registered manager to mitigate environmental risks to people living at the service. The registered manager was not aware that all allegations of abuse needed to be reported to the Care Quality Commission (CQC).

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 service did focus on some continuous learning, innovation, and improvement across the service. However, the systems in place were not always effective in identifying these improvements.

Our last inspection found that areas of the home were poorly maintained, specifically, broken flooring. At this inspection we found that several areas of flooring required replacement to promote a safe and homely living environment.

The provider had scheduled a programme of fire safety improvements in the home. CCTV had been installed at the service; this enhanced safety, security and accountability by monitoring key areas and supporting incident investigations. A Medicare call bell system had been installed at the service to enhance resident safety.

We saw records of investigations undertaken when a relative made a complaint regarding their loved one’s care. ‘To do’ actions were set following the analysis of resident and staff surveys. However, there were no set actions following the feedback provided by healthcare professionals.

Staff were being supported by the service to complete health social care qualifications. Other staff had completed train the trainer accredited courses to enable them to deliver face to face training to their colleagues.