CQC report explained · a nursing home
What the CQC found at Edgbaston Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People received their medicines safely and staff knew how to recognise and report abuse. There were some incomplete pressure care records and care recordings were not always completed promptly.
- Effective?
- Good
- Staff had suitable training and support, people's needs were assessed, and they were supported with food, drink and healthcare. Some records did not show that healthcare professionals' advice about pressure care had been followed.
- Caring?
- Good
- Inspectors saw staff treating people with kindness, dignity and respect. People were involved in choices about their care and daily lives.
- Responsive?
- Good
- Care plans included people's life stories, preferences and communication needs. The home offered activities, responded to complaints and had end of life care plans in place.
- Well-led?
- Requires improvement
- People and relatives were positive about the management team, and staff felt able to raise concerns. However, quality checks had not consistently identified risks and gaps in care records.
What inspectors found, December 2019
Edgbaston Manor is rated Good overall, but inspectors found inconsistent quality monitoring and rated leadership Requires Improvement.
This was an unannounced inspection on 25 and 27 September 2019. Inspectors spoke with people living in the home, relatives, staff and a healthcare professional. They also observed care and checked care, medicines, staffing and management records.
The home was rated Good for safe, effective, caring and responsive care. People said they felt safe, staff treated them with kindness and dignity, and their care, food, activities and healthcare needs were generally met.
The well-led rating fell from Good to Requires Improvement. The home's checks had not found some problems with pressure care records, staff following a behavioural care plan, and information about one person's diet. Some confidential information was also stored in unlocked cupboards, although this was dealt with during the inspection.
The overall rating remained Good. The safe rating improved from Requires Improvement to Good, while effective, caring and responsive remained Good. The home had identified some improvements and acted on some issues during the inspection.
Kind and respectful care
Inspectors saw staff supporting people patiently and treating them with dignity. People and relatives also spoke positively about how staff behaved.
“We observed staff supporting people with kindness and patience.” from the report
Safe medicines support
Medicines records checked by inspectors were complete. Staff explained medicines and sought people's consent when giving them.
“People were supported with their medicines safely and the Medicine Administration Records (MAR) we viewed were completed fully.” from the report
Personalised support and activities
Care plans recorded people's histories and preferences. Activities were linked to people's interests, and the home supported communication in ways people could understand.
“Care plans included "life stories" which included personalised information about people and their preferences.” from the report
Improved staffing stability
The report says the home had made improvements to provide more familiar staff and reduce staff turnover. A relative linked this to better care standards.
“Improvements had been made to ensure people were supported by familiar staff and to reduce staff turnover.” from the report
Incomplete pressure care records
needs fixingSome records about pressure care were not fully completed. Staff knew people's risks, but the records did not always show this clearly.
“In some instances, people's records in relation to pressure care, had not been fully completed.” from the report
Quality checks missed risks
needs fixingThe home's monitoring systems did not identify several issues, including pressure care concerns, staff not following a behavioural care plan and inaccurate diet records. Inspectors said this increased the risk of unsafe care.
“Whilst we did not identify any impact on people this did increase the risk of unsafe care” from the report
Records not completed promptly
minorSome staff needed more support to use the electronic recording system. Inspectors found that not all care records were completed in good time.
“On inspection we noted not all care recordings were completed in a timely manner.” from the report
Confidential information
needs fixingSome people's confidential information was stored in cupboards that were not locked. The report says this was addressed during the inspection.
“Some people's confidential information was kept in cupboards that were not locked, this was addressed on inspection.” from the report
- 01How do you now check that pressure care records are complete and that healthcare professionals' advice is followed?
- 02What changes have been made to make sure staff follow behavioural care plans?
- 03How do you check that staff understand each person's dietary needs and that kitchen records are accurate?
- 04What support and training are staff receiving to complete electronic care records on time?
- 05How will you monitor the improvements needed in the Requires Improvement well-led rating?
This was an unannounced inspection covering all five CQC questions; the previous overall rating was Good, with safe improving from Requires Improvement and well-led falling from Good. This explanation was written from the published report of 18 December 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.
Every inspection of Edgbaston Manor
Each visit the CQC has published, newest first, back to the day the home was registered.
- December 2019Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018
Registered with the Care Quality Commission on 8 June 2018.
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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Most charge £950 to £1,230 a week. 79 can care for a couple. 9 years' experience on average.
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