CQC report explained · a residential care home
What the CQC found at Edenhurst Rest Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People generally felt safe and there were enough staff, but medicines given when needed were not always recorded or understood safely. Inspectors also found contradictory allergy information, inadequate handwashing facilities and incomplete evidence of recruitment checks.
- Effective?
- Good
- Staff were trained and supported, people's consent and capacity were considered, and people received suitable food, drink and healthcare support.
- Caring?
- Good
- Inspectors saw warm and respectful relationships. Staff supported people's choices, dignity, independence, religious beliefs and social relationships.
- Responsive?
- Good
- Care plans were detailed and person-centred. People had activities, could receive visitors, knew how to complain and received sensitive end-of-life support.
- Well-led?
- Requires improvement
- The management team was described as approachable and open, but quality audits did not reliably identify problems with medicines and infection control. Handover records were also inconsistent.
What inspectors found, April 2019
Edenhurst Rest Home was rated Requires Improvement; inspectors found kind, personalised care but important weaknesses in medicines, infection control and quality checks.
Inspectors visited on 28 February and 1 March 2019 without giving notice. They spoke with people living in the home, relatives, staff and health professionals. They also reviewed care plans, medicines records, staff files and management records.
The home was rated Good for Effective, Caring and Responsive care. People were treated with kindness and dignity, received personalised support, had enough food and drink, and were helped to access healthcare and activities.
Safe and Well-led were rated Requires Improvement. Inspectors found unclear records and staff knowledge about medicines given when needed, contradictory allergy information, weak infection-control arrangements and incomplete recruitment evidence. Quality checks had not found these problems.
The overall rating remained Requires Improvement, although the report says some areas had improved since the previous inspection in January 2018. CQC said it would continue monitoring the home and could inspect sooner if concerning information was received.
Kind and respectful care
Inspectors saw friendly relationships and a warm atmosphere. Staff respected people's dignity and choices.
“We observed positive, caring and friendly interactions between staff and people.” from the report
Personalised support
Care plans included people's needs, preferences, life history and spiritual needs. Staff showed a good understanding of the people they supported.
“Care Plans were detailed, person centred and gave the reader an understanding of the persons needs both physically and spiritually.” from the report
Enough staff
Inspectors found staffing levels were sufficient to meet people's needs and keep them safe. This was an improvement since the previous inspection.
“There were enough staff on duty to support the needs of people and keep them safe.” from the report
Good support with food
People were offered meal choices and staff supported them patiently. Kitchen staff understood people's dietary needs.
“Kitchen staff were very knowledgeable about people's specific dietary requirements and there was regular communication with care staff to monitor people's requirements.” from the report
Healthcare support
The home arranged visits and referrals from health professionals when needed. Inspectors found this support was timely.
“Feedback from visiting health professionals confirmed this happened in a timely manner.” from the report
Medicines records and allergy information
seriousStaff did not always understand or record medicines prescribed to be taken when needed. Allergy records contradicted pharmacy records, creating a risk that someone could receive an unsafe medicine.
“This could lead to confusion for the staff member administering the medicine and risk of receiving unsafe or potentially harmful medicine for the person.” from the report
Infection control
seriousSome areas were not sufficiently clean and suitable handwashing facilities were not available in people's rooms, communal areas or bathrooms.
“Adequate handwashing facilities were not available in people's rooms or communal areas.” from the report
Recruitment evidence
needs fixingThe home carried out recruitment checks, but it could not always show evidence of identity checks and current clean DBS checks for all staff.
“However, we found that evidence to support these checks was not always available.” from the report
Quality checks
needs fixingAudits did not identify the medicines and infection-control problems found by inspectors. This meant the home's own monitoring was not reliably finding or responding to risks.
“Not all audits were effective at identifying and responding to risk and concerns.” from the report
Inconsistent handovers
needs fixingSome handovers were not detailed and the quality varied between shifts. Night-to-day handover was verbal and not recorded, which made information harder to follow up.
“The lack of formal recording for all handovers and the variable quality of other records meant we had difficulty obtaining the information we required in a timely manner.” from the report
- 01What has been done to make sure medicines prescribed to be taken when needed are correctly recorded and understood by staff?
- 02How are allergy records checked against pharmacy records, and how will you prevent unclear or contradictory information?
- 03Have suitable liquid soap and paper towel facilities now been provided in bedrooms, communal areas and bathrooms?
- 04How do you check that cleaning is complete and recorded clearly in every area?
- 05How are night-to-day handovers now recorded and checked for completeness?
This was an unannounced planned inspection covering all five CQC questions, including both the premises and the care provided, and it followed the Requires Improvement rating published in January 2018. This explanation was written from the published report of 17 April 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2018
Inspected but not rated; inspectors found major safety and management improvements, but some care records still needed attention.
This was an unannounced focused inspection on 10 April 2018. Inspectors checked whether the home had acted on problems found during the comprehensive inspection in January. They looked only at safety and how the home was managed.
Inspectors found that the home had made the required improvements. Safeguarding concerns were now escalated and investigated properly. Risks such as falls, stairs, windows, cleanliness and medicine storage were being managed more safely. Quality checks had also been introduced.
The home was no longer in breach of the three regulations identified at the earlier inspection. However, inspectors found one person's significant weight loss was not properly recorded or monitored. The service was not given new ratings at this visit. Ratings for the other areas carried over from the previous comprehensive inspection.
Better risk management
The home had moved from reacting to risks to assessing them and putting measures in place. Examples included safer bedrooms, sensor mats and controls around the stairs.
“At this inspection we found the provider had made significant improvements in managing the risks to people's health and safety, and as a result were no longer in breach of this regulation.” from the report
Safeguarding procedures
Safeguarding concerns were now referred to the local authority and investigated. Staff understood how to recognise and report possible abuse.
“We saw records of previous safeguarding concerns showing how the provider had worked with the local authority to ensure thorough investigations had been carried out.” from the report
Regular quality checks
The manager had introduced daily and monthly checks on care records, medicines, cleaning, equipment, fire safety and infection control. These checks were used to identify and address problems.
“During this inspection, we found the provider had introduced systems and processes that meant there was robust monitoring of the service, and they had acted on any issues they had found during the regular monitoring of the service.” from the report
Weight loss not fully managed in records
needs fixingOne person had lost 5kg in a month, but the care plan did not explain how this was being managed. Weight monitoring and food and drink monitoring had not been increased, and one staff member did not know about the weight loss.
“This lack of information in the person's care file and poor use of the person's weight assessment tool put the person at risk of not receiving the care they required.” from the report
Safeguarding training still incomplete
minorMost staff had completed safeguarding training, but four staff members still needed to do it. The manager said this was planned within the following two weeks.
“During this inspection we saw the training record that showed the majority of staff had completed this training.” from the report
Accident process not yet tested
minorThe home had introduced a process to investigate and learn from accidents and incidents. Inspectors could not assess how well it worked because there had been no accidents or incidents since it was introduced.
“However there had been no accidents or incidents since they had introduced the process.” from the report
- 01How do you now identify, record and respond to significant weight loss?
- 02How do you monitor people's food and drink intake when their appetite or health changes?
- 03Have all staff, including managers, now completed safeguarding training?
- 04How are the new daily and monthly audits checked to make sure problems are actually fixed?
- 05What were the ratings and findings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 12 May 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Edenhurst Rest Home
3 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- April 2019Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2018Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- March 2018Requires improvementdown from GoodSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2015GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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