Edendale Lodge

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

The culture of the service was positive and one where learning was part of every day practice. The registered manager was available and approachable to staff, people and families. The staff team felt valued and well supported in their roles, and able to ask anything or make suggestions for improvement of the service. There were systems in place to monitor the quality of care, however the action taken was not routinely documented.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff spoke to us about the vision of the service. One staff said, “We have total commitment to being a home that provides good quality care. We will be an outstanding home. We know we’ve got things to do, but we will do it.” Staff said that the manager and provider are approachable and keen to listen, and that they feel well supported. The registered manager and staff understood and supported people’s cultural and spiritual needs. People were treated equally and their individual needs were met in line with their preferences. The management team knew people well and also worked alongside staff to support and promote good practice. All the staff were positive and proud of the care delivered to people at Edendale Lodge.

Feedback from staff was consistently positive and enthusiastic. The service aimed to give people consistently good care and staff worked together to try and achieve this. Individual staff supervision and group team meetings were used by the provider to remind staff about their organisations underlying core values and principles.

Staff said about the registered manager, that they are, “Visible and helps out on the floor.” Another staff member told us, “We have a very good manager who shares with us and has time to listen.” One staff told us they feel the manager is very inclusive and makes sure they have time for everyone, no matter what shift they work on. The registered manager was committed to improvement and was open and transparent regarding the improvements made and those that were on going. We were told that the focus of the service was to ensure people were safe and happy, and that any learning was taken forward positively.

The registered manager worked the same shift pattern, for example 8am to 8 pm, as staff and this gave her the opportunity to review staffing levels and observe people at all times of the day. There were systems and processes in place to support staff development and progression within their roles. They talked of how they were supported to gain qualifications and extend their role, for example Care home assistant practitioners (CHAPS) and a manager’s qualification in care. Senior care staff were supported to be become medicine givers and received support and training. Regular supervisions, spot checks, competencies and values-based supervisions took place. The provider’s senior management visited the home regularly and provided support and supervision to the registered manager. The registered manager told us she attended organisational manager meetings which enabled learning across the organisation to be shared and relevant lessons learnt implemented within the home. The provider supported the registered manager and staff to attend external training, conferences and meet with other providers and managers to network through various forums. On discussion with the registered manager, she spoke of their recruitment practices and how they managed recruitment at senior management level to ensure safe recruitment.

Staff told us that felt able to raise concerns. One staff said, “I wouldn’t hesitate to voice any concerns – we can do it anonymously if want to, but I totally trust my provider and manager to take things forward – we have an open relationship.” The provider and registered manager understood their responsibilities under the duty of candour. The Duty of Candour is to be open and honest when untoward events occur.

We have received notifications as required. During our assessment we found that the management team were open and transparent. They admitted when things had gone wrong and demonstrated how they had used these to make improvements. Staff were supported and enabled to voice their views and concerns. They were aware of the whistle blowing policy but felt that they could raise them and be listened to. The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance. People and their relatives confirmed they knew how to complain, and a copy of the complaints policy was available in the home and on the service website . Relatives told us; they would make a complaint if they needed to, but would talk to staff first. A record of complaints was held in the service. These included the information on the complaint and how this was responded to. We saw complaints had been responded to and actions taken as necessary. People and relatives confirmed that the provider kept their website up to date -the website however states nursing is provided at Edendale Lodge and we have informed the registered manager of this as it may be misleading to those looking for a care service.

Staff told us, “We are like a family here – we have a good team.” All staff said they enjoyed working at Edendale Lodge and would highly recommend it as a place to work. Staff felt they were treated as individuals and their needs were taken into consideration, such as shift times being arranged to fit in with family commitments.

There was a strong ethos at the service of treating people as individuals, this extended to the workforce as well. However the documentation to support this were not always completed in full. There were robust measures in place to monitor, maintain and promote good mental well-being across the staff group. Staff were encouraged to undertake training in equality and diversity.

Staff told us, “There are lots of audits that we do so we can get a good overview. We have to complete checklists.” Some staff told us that these were not always fully completed and that this is not helpful and leaves gaps.

Quality assurance systems were in place and were being used effectively to improve the service. There were areas that need to improve to ensure outcomes and actions were clearly documented. The management team were working to ensure there was oversight and effective governance at the service. There were computerised systems and processes to assess, monitor and improve the quality and safety of the service provided. This included health and safety, accidents, incidents, complaints, medication records and staff documentation. However there were very strong odours in some areas of the building, this had not been raised or identified within audits and check lists. This has been immediately actioned. Incidents were not always followed up with an action plan to prevent a re-occurrence and linked to behavioural risk assessments or care plans Fluid charts were discussed as there was an inconsistency in how staff recorded people's fluid intake. This could mean that staff might miss a change in peoples' fluid intake. This was acknowledged and steps taken to address this issue. The people at risk from dehydration were closely monitored. Areas of people's documentation lacked reflection of staff management of certain behaviours that may distress. Changes to peoples fluctuating mental health and their capacity status was known by staff but not clearly considered or then documented. This included submitting DoLS applications for covert medicine administration.

People told us of trips they had been on in the minibus to local parks and garden centres. One relative told us that events such as birthdays are seen by staff and managers as an opportunity to celebrate and plan a party.

Staff told us how trips are arranged to match with people’s hobbies and interests, such as gardening, parks, feeding ducks and going to pubs. Staff said they have good relationships with other health professionals and one staff told us, “We work together to get good outcomes for people.” The registered manager said that people were part of their local community. They said, “We are arranging trips out and inviting people in -such as local schools and churches.” The registered manager had recently arranged for one person to be visited by a religious representative. They worked closely with external professionals and told us they would be confident to contact someone directly without hesitation

Health professionals told us that they have a good relationship with the service and staff work with them in a professional and knowledgeable way. One told us, “I think they sometimes may be over worried about people, but I would prefer that. Better safe than sorry.”

The registered manager and provider were proactive in building relationships with other organisations and into the local community to improve outcomes for people. They told us how they had contacted the local council about using their large garden for allotments for local people which would allow people who live there to be involved if they chose to. They had close links with the local authority and utilised any additional training opportunities when they were offered.

The manager told us how staff were mindful of the environment and sustainability. One staff member had approached her with concerns about how many disposable plastic aprons they were using. The registered manager considered this suggestion, and then purchased fabric washable tabards. The registered manager rewarded the staff member for her insightful idea with a gift voucher. The registered manager also told us how they have reduced their use of tumble drier to save on costs and energy usage and are now drying clothes on the washing line more often.

People and their relatives had opportunities to feedback their views about the service and quality of the care they received. People and relatives all described the staff and management of the service as open and approachable. Staff supported people to give feedback and opportunities which they had to drive improvements and encourage learning from any incidents which occurred. The provider and registered manager had oversight of accidents and incidents. Trends and patterns were identified and addressed. For example, introduction where appropriate of crash mats and sensor alarms. We saw example of lessons learnt following incidents which occurred within the service. Reflective meetings were held with staff to give opportunities to discuss development points to encourage improvement in practice. Learning was, where appropriate, also shared across the providers other services. The registered manager encouraged staff to speak up about positive ideas.