Edward House

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

During our assessment, we identified three breaches of the legal regulations under safe. These were for safe care and treatment, safeguarding, and staffing. Safety risks to people were not always managed well and risks were not always assessed. People were not appropriately involved in decisions about managing risks, their care plans, their medicines or assessments, after their initial assessment. There was no reflective practice record or safeguarding register completed. There were no processes or systems in place when incidents had occurred to review what had happened and prevent re-occurrence. Lessons were not learned from safety incidents or complaints. The provider had safeguarding processes in place, but they were ineffective. Staff had not always followed their training when supporting people with moving and handling which put them at risk of harm. Many staff did not receive relevant training to meet the range of people’s needs at the service including infection prevention control and safeguarding training. This meant staff were not appropriately trained to respond to safeguarding incidents. There were not enough staff to support people with their needs. Staff did not receive support through supervision and appraisal to support their continuous learning and improve their working practice. The provider did not complete competency checks following staff training to ensure staff understood the training. Staff were not always deployed effectively throughout the building which potentially placed people at risk of harm. People were not always protected from this risk of infection. Staff did not always follow national infection, prevention, and control practices. There were clear processes and policies, to ensure the environment was kept clean and hygienic but staff were not following this. Medicines were not always managed safely. Medicine audits had been completed but these were ineffective as they had not identified concerns we found during the assessment.

This service scored 50 (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 processes or systems in place to promote a learning culture. This meant there were missed opportunities to reflect and to ensure learning and improvement could occur. The provider had been inspected by the local authority in May 2023. Following this, the local authority raised concerns. We found similar concerns during our assessment which took place in March 2024. This meant the provider had failed to take action and learn lessons when things had gone wrong.

People and their relatives told us, they had not been given the opportunity to be involved in any learning at Edward House. One relative told us, “‘No not really [involved in learning from incidents], I only speak to staff to get a receipt for pocket money given.”

Staff felt there was not a learning culture at Edward House. Staff were also, not given an opportunity to be involved in learning and did not feel confident to raise concerns or ideas to the management team. A staff member told us, “I did feel supported, it's just quite hard to say with how the management are at the moment. We are under a lot of stress and not feeling assured from them. I do not feel I can go into the office or talk to the manager, even if I had an idea. I feel it brings me anxiety.” Staff told us they did not have regular staff meetings or supervisions. A staff member told us, “I have worked here for over a year and not had a supervision. My last supervision was when I did shadow shifts.” This meant staff were not provided with an opportunity to reflect or review what was working well and share ideas on where improvements could be made. Management feedback confirmed there was no learning culture. A manager told us, they complete a monthly audit to review incidents and accidents to identify patterns and trends. However, management were not able to explain what processes and system were in place to learn from incidents.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We observed staff did not always take action to mitigate identified risks in line with their training to protect people from abuse. For example, we observed two people who were verbally abusing each other. Staff did not take action or put measures in place to protect people. The incidents reoccurred 2 more times during our onsite assessment. At each incident were observed both people were distressed and agitated. This meant people were at risk of emotional abuse.

People told us they felt safe. A person told us, they feel safe “Every time, because I feel alright, if I wasn’t alright, I wouldn’t stop here.’ Another person told us they “Felt safe all the time, a friendly atmosphere that’s it.”

The provider had processes in place, but they were ineffective. Only 39% of the staff team had completed safeguarding training. This meant staff were not appropriately trained to ensure they knew how to respond to safeguarding incidents. Monthly accident and incident report had been completed but management had not identified areas of concerns and where improvements could be made. The audits had not been shared with staff or people living at Edward House to ensure lessons were learnt. This meant people were not always protected from identified risks. The management team had not followed their own processes. They had not completed reflective practice records or a safeguarding register for Edward House.

The management team told us, “We have a safeguarding audit we complete monthly, also complete a reflective practice record and use a safeguarding register.” However, we found the management team had not followed their own processes because there was no reflective practice record or safeguarding register completed for Edward House. Staff and the management team understood how to respond to allegations of abuse. Staff told us that they would tell the senior carer or management team but not all staff were aware of the whistleblowing policy. A whistleblowing policy would be something staff would use if they felt concerns were not being responded to. A staff member told us, “No, I do not know how to whistle blow.”

People were unable to explain how they were involved in managing their risks and what choice’s they had. People told us they had not been involved in their care plans or assessments. This meant people were at risk of not receiving care and support to manage their risks in a person-centred approach. People told us that staff understood their needs well and offered support to keep them safe. One person told us, “I need a bit of support, I get support walking when I need it.”

The provider did not have an effective process to involve people to manage their risks. The management team told us people are involved in managing risks during the admission assessments. This meant there was no processes for people to be involved after their initial assessment. Staff were unable to explain how or what processes were in place to involve people in managing risks. Staff told us it is not their role to complete risk assessments to identify risks or put measures in place.

Care plans and risk assessments did not demonstrate people were involved in managing risks. Risks to people were not always clearly documented in their care plans to ensure people's needs and risks were mitigated or managed safely. For example, one person’s care plan had conflicting information regarding their diabetes care, support, and treatment. Another person's care plan stated they had epilepsy, and they were at risk of seizures. However, there were no person-centred guidance in place for staff to follow in the event of a seizure. This placed both people at potential harm. There were no processes or systems in place when incidents had occurred, for staff and people to review what had happened and ensure measures were put in place to prevent re-occurrence of incidents.

Risks were not always managed safely. We observed staff had not always followed their training when supporting people with moving and handling. We observed staff using unsafe moving and handling techniques on 3 occasions when supporting people with their mobility. This placed all three people and staff at risk of harm. Since our inspection, the provider has taken action and organised re-training for all staff to complete on moving and handling people.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We observed that staff were not always deployed effectively throughout the building which potentially placed people at risk of harm. During the inspection there were substantial periods of time where inspectors were unable to locate staff members and people were left unsupervised in communal areas whilst requiring assistance meaning people’s needs were not met safely or effectively. We observed emergency alarms had been triggered by people and staff took longer than expected to respond to those alarms.

Systems and processes did not always ensure there were enough competent staff on shift. This placed people at risk of not receiving safe care and support. This was raised with the management team, and they acknowledged the gap in staff competency and told us they would review and update the rota to balance the skill mix of staff. The training programme was not comprehensive to meet the needs of people and staff. Staff had not received training on how to support people’s individual needs. For example, we observed some people living at Edward house were living with diabetes, a learning difficulty, and/or epilepsy. However, staff had not completed training in these areas. This meant staff were not appropriately trained to ensure people were supported safely. Staff had completed training courses for medicines management, infection and prevention control and moving and handling. However, the provider did not complete competency checks following their training to ensure staff understood the training and put their learning in practice. Training attendance alone does not demonstrate staff understanding, or that staff would be adhering to and implementing the training. The was no process or system for staff to have regular one to one supervisions or staff team meetings. This meant staff were not provided with an opportunity to discuss, reflect, or review what was working well, and what could be improved at the service. The provider did not always follow safe recruitment processes. We observed that documents had not been completed in full, including application forms and interview notes, and one file reviewed only contained 1 reference. Staff had all had a Disclosure and Barring Service (DBS) check. A DBS check is a way for employers to check an employee criminal record, to help decide whether they are a suitable person to work for them.

We received mixed feedback from people regarding staffing levels. Some people told us there was not enough staff. One person told us, “No there isn’t enough, some of them have left and gone to another job.” Another person said, “Yes, we’ve never had anything desperate, we help each other, we go through any problems and deal with it.”

The management team told us they used a calculation tool to assess how many staff were needed to meet people’s needs. However, staff told us they felt there wasn’t enough staff on each shift to meet people’s needs safely. One staff member said, "No not enough staff at all. An example is we have a lot of agency staff and risks are not managed. The agency staff are not given inductions and we have no time to explain people's needs and risk. Weekends we have no management, and not always tea meal preparation staff to support so we have a lot more to do at weekends. On top we have agency staff who don't know people. We're not able to provide person centred care and support or manage peoples risk safely. So many tasks to do and complete paperwork. I understand we have to complete paperwork, but we do not have enough staff to make sure there is a safe service and paperwork is completed.” Another staff member said, “Not really have enough staff, I think that’s where we lack on that side of the job. Especially at weekend we are overly ran by agency. Sometimes we get the same agency and that’s not as bad but when they not been before they don’t know the residents.”

There were clear processes and policies, to ensure the environment was kept clean and hygienic but we observed staff were not following this. Only 50% of the staff team had received training in infection prevention and control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak. This meant that not all staff were not appropriately trained. People were able to receive visitors without restrictions in line with best practice guidance. Since our on-site assessment, the provider had updated their practice on washing usable medicine equipment in line with national guidance.

People told us that the home was always kept clean. One person told us, “Yes definitely [clean], bathroom yes spotless.” People also told us their bedrooms were cleaned daily.

Staff confirmed they had completed infection prevention and control training. However, we were not assured that all staff were competent in putting their training into practice. Management told us they had a cleaning schedule in place for staff to complete and the record was reviewed by management the following week to identify any concerns or risks.

People were not always protected from this risk of infection. We observed staff had not always followed national infection prevention, and control practices. For example, we observed an incident where a person had vomited. Not all staff supporting the person had worn personal protective equipment. This meant people were not protected from the spread of infection. The entrance hall of Edward House had a strong malodorous smell. Management was aware of this and told us they had plans in place to have the flooring replaced. During our assessment we did observe 2 domestic staff during the morning shift. The provider failed to ensure staff followed infection prevention and control guidance regarding the use of re-useable plastic medicine equipment. We observed staff had washed re-usable medicine pots, oral syringes and medicine spoon with water and a dirty cloth in a hand washing sink. The guidance states these should be washed in hot soapy water and not in a hand washing sink. This meant people were at risk of cross contamination and risk of harm.

Medicines were not always managed safely. The opening and expiry date for oral drops, and topical creams was not consistently recorded. Therefore, there was a risk these could be administered after they had expired. Medication records for pain relief medicines had not been signed stating people had not received their medicines. Management confirmed these medicines had not been administrated. This meant people had not received their prescribed pain relief as required and could have been in pain. Some people at the service were prescribed controlled drugs. These are subject to enhanced restrictions due to the addictive nature of these medicines. We saw staff had followed national legal requirements by storing these medicines in an extra secure place. There was not effective oversight of medicine management. Medicine audits had been completed. However, these were ineffective as they had not identified concerns we found during the assessment. The provider failed to ensure staff were competent in administrating and completing medicines audit. This meant people were at risk of not receiving their medicines safely. Information regarding people’s medicines was not recorded clearly or accurately in their care plan. We observed errors in relation to 1 person’s medicines needed to manage diabetes. This has not negatively affected the person at the time however, it did present a risk of the person receiving incorrect support and treatment. Since our on-site assessment, the provider had taken action and arranged refresher medicines training and competency checks by an external training company for staff. They have also organised for a medicine audit to be completed by a competent member of staff.

People were not given the opportunity to be involved with their medicines support and care. However, people told us that staff supported them with their medicines safely. One person told us, “They [staff] do tell me that they are giving me them [medicines], swallow, watch you take them.”

Staff told us they had received medicines training, but some staff had not had a competency check. One staff member told us, “I’ve never done medication before. I did an online course for one hour. I have not been competency checked. [name] is supposed to check, I think. But, I have never, and I administer medicines.” This meant people were at risk of not having their medicines administered safely. Staff were able to explain where the medicines policy was located. However, told us they had not been given time to read the policy.