Edward House

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• 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

During our assessment, we identified a breach of the legal regulations for governance. The provider failed to ensure good governance systems were in place to assess, monitor and mitigate the risks to people, maintain accurate or up-to-date records of people's care or the management of the service. There was not clear and effective governance, management, and accountability arrangements. Staff did not understand their role and responsibilities. Managers failed to be accountable for the actions, behaviours, and performance of staff. The systems to manage current and future performance and risks to the quality of the service did not take a proportionate approach to managing risk. We were not always assured that data or notifications were consistently submitted to external organisations as required. There were not robust arrangements for the availability, integrity and confidentiality of data, records, and data management systems. Information was not used effectively to monitor and improve the quality of care. Leaders had not implemented relevant or mandatory quality frameworks, recognised standards, best practices, or equivalents to improve equity in experience and outcomes for people using services and tackle known inequalities.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

People received a service that was not well-led. There was not always a capable, compassionate, and inclusive leader who was managing the service. There was no registered manager in post at the time of our inspection. There have been 3 management changes in the last 5 months. A deputy manager was in post however the provider failed to ensure they had received appropriate training and checked their competency to be able to do their role effectively. The provider had not ensured they checked all staff competencies to ensure they could safely carry out their role in line with their training and good practice. The staff team were not always aware of their role and responsibilities at the service. There was a lack of management oversight. Staff were not supported to understand their roles and responsibilities. This led to people being at risk of harm due to being exposed to ongoing unsafe care practices. Audits were not completed by capable staff and were not robust. Staff and management failed to adequately identify and address shortfalls in the safety of the service, including, medicines management, care planning, risk management and staff training. Systems to ensure equipment was in place in the event of an emergency were not effective. We observed, a person who became unwell and required to use of a hoist to ensure safe moving and handling. However, the provider failed to ensure they had the correct size sling available. The management team had to request one from another nearby care home which is overseen by the same provider. This meant the person had to wait for an inappropriate amount of time before they could be supported.

Edward House has had 3 management changes since September 2023. A senior manager had taken over the management of the home and been in post for 3 weeks. We raised our concerns and had been provided with assurances that the senior manager will be managing the service. The senior manager told us that staff had not been supported, empowered, or been provided with the right training and support to do their roles effectively. The Management team were not always capable, compassionate, and inclusive leaders. Staff told us they were not encouraged to speak up or, discuss their concerns openly. When staff had raised concerns, staff felt the management team were not capable of taking action. Staff felt they could not raise concerns or risks, even when staff knew things were wrong. One staff member told us, “Not listened to everything gets brushed under the carpet. There is lack of management skills to know what to do. They speak down to you. We do need to change and how we work but their approach isn't well. The management do not know the residents well. We are giving 110%, but when we raise concerns, it is disheartening because no action is taken when concerns are raised.” Another staff member said, “[person] does not have management and leadership of the home [name] is walked all over.” Staff had not been supported when they had raised concerns. A member of staff told us, “I do not feel comfortable to raise concerns with the management because when I have, they do not take any action. They do not deal with the concerns they just shrug their shoulders, and nothing changes.” Staff did not feel respected by the management team. A staff member told us, “Management team are not approachable the way they talk to us is disgusting. I understand they have got targets they need to hit but they are not good leaders and not treating the staff well. You cannot talk to the management they do not listen. No, the home is not managed it is hectic.”

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 provider had failed to ensure robust governance processes were in place to monitor the safety and quality of people’s care. An audit process had been implemented; however, it was ineffective because the audits had not identified concerns and all audits completed showed the service was safe. The failure to have effective oversight in place restricted the ability to identify risks to people and address concerns. The provider had not implemented adequate processes to provide assurance of the effective management of the service. Staff had been allocated tasks that had not been effectively completed. For example, care plan reviews with no management oversight or checks completed. The management team had failed to identify gaps in staff knowledge and competency, and the staff skill mix had not been considered when completing the rota. This meant that people did not always have access to competent and appropriately skilled staff. The provider failed to ensure there was an effective system or process for people, staff, relatives, and visitors to be involved in developing the service. The provider had no engagement with people to obtain their feedback to improve and develop the service. This meant opportunities were missed to identify concerns, risks, and areas of improvement. The provider failed to have effective systems and processes for continuous learning and improving care. Concerns, risks, poor practice had been shared with the provider by the local authority and we found the same risks remained due to the lack of action taken by the provider to improve the quality of care. Lessons were not being learnt due to the lack of oversight by the provider or their management team. This left people in receipt of poor care and treatment. The provider had relevant policies in place. However, failed to ensure staff were given the time to read the policies and that staff were checked to ensure they were able to confidently put the guidance into practice.

The provider failed to ensure there were effective and robust systems and processes in place to manage concerns and risks. The management team could explain the risks and concerns at Edward House. However, failed to ensure measures were put into place to mitigate the identified risks. For example, the management team told us that audits had been completed but they were not a true reflection of the service because the staff competing the audits were not competent. The management team were able to explain what processes, systems and procedures needed to be implemented but did not have a clear plan on who, how and when these concerns were going to be actioned.

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.

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