Edendale Lodge

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

People received safe care from staff who knew them well and understood their risks and how best to support them. Systems were in place to keep people safe from abuse and harm. Staff were recruited safely to ensure they were suitable for their roles. Some processes and documentation were in need of improvements and these were underway by the end of our assessment.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People who were able to speak with us, and relatives and visitors told us they felt able to raise any issues, and matters were responded to positively and promptly.

Staff gave examples of where they had worked together as a team alongside management to learn from incidents and events. One staff said, “If we received a complaint, we would discuss it at the team meetings and then make adjustments.” Another told us, “We can always learn – we might not know everything, but we will learn from advice.”

Safety concerns and events were investigated and reported on, and lessons were learned to embed good practices. The provider had used learning from events/incidents at other services within the group to improve oversight of care and ensure peoples safety. There had been a recent safeguarding investigation in which the registered manager acknowledged improvements were required to their admission assessments and respite care plans. We were shown the new and improved documentation and assessment which will protect people from inappropriate care going forward. Safety checks were undertaken by staff, this included environmental checks, and risk assessments for both physical and mental health. This enabled the management team to embed the culture of continuous improvement. Accidents, incidents and changes were discussed and documented in meetings and in supervision meetings.

We received varied responses from family members about the initial transition for their loved ones into the service. Some felt that vital information had been missed in the assessment of the person’s needs. The service have recognised some weaknesses in this area and have since made improvements to their processes which we have referred to in the processes sections of this report. One relative told us that they were kept informed of appointments and referrals to specialists. They said, “They keep us up to date, and if we can, we will go with our relative – if we can’t, a staff member goes with them.”

Staff worked alongside other ASC and health organisations to ensure people received appropriate care. There was regular contact with local authority, social worker, paramedics and doctors. Staff told us they knew the paramedics and health team well and told us of collaborated team work. "We know the surgery really well now, and I think we work well together, they are always helpful and answer our queries."

We spoke with two health care professionals who told us staff sought advice when needed and picked up when people were unwell. One said, "They are knowledgeable about their residents, They are open to advice.”

People were supported to maintain their health, attend appointments both inside and outside of the service. People's care records showed prompt referrals had been made to healthcare professionals where concerns had been identified. Whilst we were told that people were assessed before a placement at the home was offered, the documentation to support this was not robust. It lacked detail about peoples’ health status and the admission process had not always included a thorough physical assessment and risk assessments. This was acknowledged by the registered manager, and improvements had been made and were on-going. The management team worked to ensure continuity of care, including when people moved out of the service and on to new placements. When people were supported to go to hospital passports were used. These ensure that hospital staff have vital information about them and their health. Not all people had a hospital passport and the registered manager started to review this immediately to ensure they are in place.

Only one person could tell us how they felt about living at the service. "It’s safe here, I don’t worry about anything, I know how to contact staff - I ring the call bell." A visitor told us, “I am very pleased with the care here, I know my relative is safe and happy. Our observations found that people were comfortable with staff we saw positive interactions.

Staff we spoke to were confident and knowledgeable about safeguarding. They knew how to notice signs that abuse may be occurring and how to raise alerts and report concerns, by whistleblowing if necessary. Staff knew people well and could describe their difficulties and how to support them individually. One staff told us, “The manager’s door is always open, we don’t have to wait.” Another told us how they have regular training refresher courses to keep their knowledge up to date.

People were supported by staff who knew them well. Staff supported people with kindness, respect and followed good practice guidance when assisting them - for example, directing them to the bathroom, or to the lounge. One person was assisted from their chair and struggling to get up -two staff patiently explained where the person should place their hands and then helped them to stand.

There was a safeguarding and whistleblowing policy in place, and staff confirmed they had read the policies as part of their induction and training. We saw that procedures had been correctly followed, and the provider had made referrals as required to the local authority and notified CQC appropriately. There was a file kept by the registered manager of all the DoLS submitted and their status. The documentation supported that each Dols application was decision based. Feedback from staff and leaders supported that each Dols application was decision specific for that person. For example, regarding restricted practices such as locked doors, crash mats and sensor mats, We saw that the conditions of the DoLS had been met. However one persons DoLS was incorrect regarding medicine administration and did not include covert administration. An urgent DoLS was immediately applied for.

One person told us, “They talk to me about my care and what I need help with. I feel safe.” A visitor said about their relatives and risks, “They are definitely safe here, they went through everything about risk, and involved us in all of the care decisions.”

Staff told us they have enough information about people’s risks to guide them on how to minimise those. They said they attend meetings with management to discuss individual’s risks and to consider changes and improvements. Staff told us they read the care plans, and monitor areas of concern. One said, “If someone falls, we check their risk assessment and update their care plan. It’s part of our job to keep people safe.”

We observed staff promoting people’s independence, safety and attending to people promptly when they needed assistance. Equipment had been well maintained and regularly serviced. We saw some areas of the service where there were issues with cleanliness and some fittings in disrepair.

Care plans and risk assessments included clear guidance for staff on how to minimise risks. Some records, for example for people at risk of dehydration, were inconsistent. We found gaps in records relating to behaviours caused by distress, which meant that staff may be unaware of potential triggers, and how to respond in the most supportive and effective way. This was acknowledged and addressed by the registered manager during our assessment process. The registered manager undertook an analysis of incidents and accidents and referrals were made for additional support where required, for example, in reach team, falls team, assistive technology, and GP involvement. Systems and procedures were in place for unusual events, such as fire, loss of power, and other emergencies.

Relatives told us that the environment was safe. One relative said, “Really good security, I don’t worry that they will leave without staff knowing, there is space for them to walk around without getting into trouble.” Another relative told us, “I think the home is lovely, it looks nice, the furniture is good and there are places for us to see our relative in private.”

Staff told us that they regularly check the environment for hazards. One staff said, “I feel it’s a very safe place to work.”

The premises were free of obstacles and hazards, and we observed people moving safely and independently without any staff assistance around the care home. Where staff were seen assisting people with equipment, they were doing so in a professional and safe way.

The provider had conducted comprehensive checks and audits that ensured the environment was safe and had recently completed work from a robust fire risk assessment report. Staff completed regular fire evacuation drills and any learning from them had been taken forward. Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, moving and handling equipment, staff safety and welfare. There was a business continuity plan which instructed staff on what to do in the event of the service not being able to function normally, such as a loss of power or evacuation of the property.

People and relatives spoke positively about the staff team. One relative said, “The staff are A1”. Another told us, “Absolutely fabulous, lovely staff.” We asked about staffing levels and some comments we received were, “I can always find staff when I need them,” and “There are always staff around – always someone there.”

We received mixed responses from staff about staffing levels. Some staff told us that although some days can get very busy, they feel they can raise this with the manager who will arrange for more staff to support the team. Some staff said that there are certain times of day where it can be hard to find another staff member to support them if the need arises. Staff also told us that the manager is very supportive, “The manager will always help – in fact, she is on the floor most meal times and evenings.”

We observed that staffing numbers were sufficient in the mornings and people had been supported in a relaxed and sociable manner with meals and drinks. However, we found that staff were less visible in the afternoon and people were left without support being available at times. We raised this with the registered manager who was reviewing the way staff were deployed at that particular time of day, as they felt there were sufficient numbers of staff on duty.

Care delivery was supported by records that evidenced that people’s care needs were being met. Records showed that housekeeping staffing levels were inconsistent and we saw that the home was not clean in all areas, and there were some bedroom and bathroom areas where there were offensive odours. The registered manager altered the rotas in response during the assessment, and employed two new housekeeping staff. Recruitment processes were robust, with the provider undertaking checks on new staff prior to them starting work.

Relatives did not share any concerns about the cleanliness of the environment. One said, “It’s very clean and tidy.” And another said, “I am happy with the place, it seems clean.”

Some staff said that the home can have odours at times, but that the environment is clean and the cleaners work hard. One said, “I think we need more cleaning hours.”

We saw that the home environment was kept generally clean and tidy, however there were unpleasant odours in some areas of the upper floors. This was discussed with the registered manager who made immediate changes to the housekeeping rotas, and numbers of cleaning staff to address this without delay.

Immediate action was taken by the provider to address the shortfalls in cleanliness and odours in the home. On the second day of the assessment, we were told the rooms where we had identified odours had been deep cleaned, the flooring and the vanity units in those rooms were replaced. The provider followed best practice guidelines regarding the prevention and control of infection which was updated as guidance changed. The provider’s infection prevention and control policy was up to date and all staff had received infection control and food hygiene training. Cleaning schedules were in place and were up to date and regular audits were carried out and actions planned to address any shortfalls, however these processes had not identified the issues we found with odours in certain areas of the home.

People were not able to share their views about medication, but one family member we spoke with said, “Staff keep us informed of any changes, let us know what the doctor says. I trust them totally and get informed of changes. I have no concerns.”

Staff told us they complete training before administering medicines and then have to pass a regular competency assessment. One staff said, “We take medicine giving very seriously, and we do lots of checks to make sure it is right.”

Staff who gave medicines had the relevant knowledge, training and competency that ensured medicines were handled safely. We observed staff giving medicines safely and were recorded accurately. Risk assessments were in place for certain medicines. All discrepancies and medicine errors were recorded and investigated and action taken as required. Daily and monthly audits were carried out, and any shortfalls were addressed. Protocols for 'as required' (PRN) medicines such as pain relief medicines were in place however, they were very generic and lacked personalisation. We identified that the procedures for covert medicines needs to be improved. Covert administration is when it is given hidden in food or drinks. We asked that they seek expert advice to improve practice.