CQC report explained · a residential care home
What the CQC found at Edge Hill Rest Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Medicines were stored and administered safely using a new electronic system. Inspectors also found enough suitably trained staff, suitable recruitment checks and appropriate risk management.
- Effective?
- Good
- This key question was not inspected during this visit. Its rating carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this visit. Its rating carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this visit. Its rating carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found improved management, effective quality checks and a positive culture. Relatives said communication was good and staff felt supported.
What inspectors found, April 2022
Rated Good; inspectors found safe medicines, enough staff and improved leadership.
This was an unannounced focused inspection on 28 February and 2 March 2022. Inspectors checked whether improvements had been made after the previous inspection, when the home was rated Requires Improvement and breached one regulation.
The home was rated Good for Safe and Well-led. Inspectors found that medicines were stored and given safely, there were enough trained staff, recruitment checks were completed, and the home was clean and well maintained. Staff understood safeguarding and how to manage risks.
Inspectors found that management had improved. The home used audits and checks to monitor quality, and relatives gave positive feedback. This inspection did not assess Effective, Caring or Responsive, so those ratings carried over from the previous inspection.
Medicines management
The home had introduced an electronic medicines system since the previous inspection. Inspectors found that medicines were stored and administered safely.
“Since our last inspection the provider had implemented an electronic medicines managment system.” from the report
Staffing and recruitment
Inspectors found enough suitably trained staff. Recruitment checks, induction, supervision and staff support were in place.
“There were enough suitably trained staff to support people according to their needs and wishes.” from the report
Management oversight
The manager had improved oversight of the home and used audits covering areas such as medicines, health and safety and infection control.
“The registered manager used a range of audits and checks to monitor the quality of the service.” from the report
Family communication
Relatives were positive about the home and said they were kept informed, including during lockdown.
“Relatives were happy with the way the service communicated with them and kept them informed.” from the report
Inspectors raised no specific concerns in this report.
- 01How is the electronic medicines system checked now, and what happens if a medicines record is incomplete?
- 02How do you make sure there are enough trained staff for people's individual needs and wishes?
- 03How are risks and changes in people's health recorded and reviewed in the electronic care records?
- 04How can residents and relatives give feedback through meetings or surveys, and what changes have followed from that feedback?
- 05What were the ratings for Effective, Caring and Responsive at the previous inspection, and when will these areas next be assessed?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive carried over from the previous inspection. This explanation was written from the published report of 2 April 2022 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, December 2020
Rated Requires Improvement; inspectors found medicines records were not reliable, although staffing, infection control and management were improving.
This was a focused inspection. The inspector visited on 16 November 2020 and checked whether earlier legal requirements had been met. The review covered Safe and Well-led, including medicines, staffing, records, risk checks and management systems.
The main problem was medicines documentation. Some records were not signed or countersigned, some as-needed paracetamol lacked written guidance, and records did not show where creams should be applied. Audits had not consistently made sure these issues were corrected. Inspectors found no evidence that anyone had been harmed, but said people were at risk.
There were also positive findings. The home was clean, infection control measures were in place, staffing levels were suitable, recruitment checks were completed, and staff had safeguarding and medicines training. A new management team had started improvements, but earlier problems had not been fully resolved or kept under control.
The overall rating remained Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three key questions were not inspected during this visit, so their previous ratings were carried forward.
Staffing and recruitment
Inspectors found enough staff for the people living at the home. Recruitment checks were completed to reduce the risk of unsuitable staff being employed.
“Staff were recruited safely. Pre-employment checks were carried out to protect people from the risk of unsuitable staff working for the service.” from the report
Infection control
The home had infection control arrangements and extra measures to reduce the risk from COVID-19. It was clean and did not smell unpleasant.
“The home was clean and free from unpleasant odours.” from the report
Positive views of care
Relatives told inspectors they were happy with the care and support. Staff were also described as more positive under the new manager.
“Relatives spoke positively about the support and care given to their loved ones.” from the report
Safeguarding arrangements
Staff had safeguarding training and knew how to report concerns. Whistleblowing information had been made clearer for staff.
“Procedures around whistleblowing had been strengthened.” from the report
New management improvements
The new management team had restarted quality checks, staff meetings and supervision. Some problems identified during the inspection were dealt with promptly.
“The management team were receptive to suggestions and guidance during the inspection and promptly actioned some improvements that were needed.” from the report
Medicines records
seriousSome handwritten medicine records were not signed or countersigned. Some as-needed medicines lacked written instructions, and cream application records did not initially show where creams should be applied.
“Some hand-written medicine administration records had not been signed or countersigned by staff to ensure the doses of medicines and times to be given were correct.” from the report
Weak quality checks
seriousMedicine audits were not reliable or regular enough. An audit had identified the need for body maps, but this had not been put into practice.
“Medicine auditing processes were not robust and had not been carried out consistently.” from the report
Previous improvements not sustained
needs fixingProblems found at the previous inspection, especially around medicines, had not been fully fixed or maintained. Inspectors said management oversight had previously been poor.
“Previous management oversight of the home was poor and areas in need of improvement identified at our last inspection had not been fully addressed, notably in medicines management.” from the report
Safety follow-up
needs fixingEmergency lighting had failed a recent service check and urgent maintenance had not been arranged until after the inspection. Risk assessments for staff at higher risk from COVID-19 were also completed only after the inspection.
“No action had been taken to ensure urgent maintenance work was carried out when emergency lighting had failed a recent service check.” from the report
- 01Did the electronic medicines management system begin at the end of December 2020, and has it fixed the missing signatures, guidance and cream application records?
- 02How often are medicines audits now completed, and who checks that identified problems are actually corrected?
- 03What action has been taken to make sure emergency lighting and other urgent maintenance issues are dealt with without delay?
- 04How are risk assessments for staff at higher risk from COVID-19 kept up to date?
- 05How has the new management team shown that improvements have been sustained since this inspection?
This was a focused inspection of Safe and Well-led only, checking Regulations 12 and 17; the other key-question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 12 December 2020 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 Edge Hill Rest Home
6 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- April 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- July 2018Goodup from InadequateSafe: GoodWell-led: Good
- September 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2015
Registered with the Care Quality Commission on 24 August 2015.
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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