CQC report explained · a residential care home
What the CQC found at Edgecumbe Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2024
Rated Requires Improvement, with Safe rated Inadequate; inspectors found serious risks in the building, fire safety and management oversight.
This was an unannounced inspection on 22 and 26 June 2023. It began as a targeted inspection after health and safety concerns from the local authority. Inspectors widened it to a focused inspection after finding further environmental risks.
The home had some strengths. Medicines were managed safely, there were enough staff, and people had care plans covering their needs. Staff and residents generally spoke positively about the home and its management.
However, inspectors found unsafe premises, fire doors that did not close properly, an out-of-date fire evacuation folder and poor infection control in parts of the building. The home’s checks had not identified these problems. The provider was in breach of Regulations 12, 15 and 17, and warning notices were issued for Regulations 15 and 17.
The overall rating remains Requires Improvement. Safe fell from Requires Improvement to Inadequate. Effective and Well-led remained Requires Improvement. This was the home’s third consecutive Requires Improvement rating.
Medicines
Inspectors found that medicines were stored, administered and checked safely. Staff had completed training and had their competence assessed.
“Medicines were stored, managed, and administered safely. Medicines were administered by staff who had completed training and had their competency assessed.” from the report
Staffing
Inspectors found enough staff to meet people’s care needs. Recruitment checks were generally completed, including interviews, references and DBS checks.
“There were enough staff employed to care for people safely.” from the report
Care planning
People had assessments and support plans covering their personal care, communication, health conditions and preferences.
“The records we reviewed had holistic assessments with individual support plans for people's identified care needs such as personal care, communication, vision and specific health conditions.” from the report
Supportive culture
People and staff gave positive feedback about the manager and the staff culture. One person said they felt safe and that staff were kind.
“One person told us "I feel safe, the staff are kind.” from the report
Fire and environmental safety
seriousSome fire doors did not close properly. Inspectors also found missing window restrictors, frayed cables, trip hazards and other maintenance problems.
“Some fire doors on the ground floor of the home did not close properly.” from the report
Infection control
seriousThe laundry room lacked a full floor covering and a handwashing sink. Broken tiles, unclear laundry storage and worn surfaces made good infection control difficult.
“The laundry room environment had not been updated. The flooring did not cover the whole area and there was still no sink available for staff to wash their hands.” from the report
Weak management checks
seriousAudits and spot checks had not found several problems identified by inspectors. Management oversight was not clear or effective.
“The evidence outlined above demonstrates systems and processes for good governance were not operated effectively.” from the report
Best-interest records
needs fixingCapacity assessments were completed, but records did not consistently explain how best-interest decisions had been made or who had been involved.
“However, we did not consistently see documentation in place which showed how best interest decisions had been reached and who had been involved.” from the report
Relatives’ feedback
needs fixingThe home did not have a system for gathering relatives’ views. Feedback from relatives was mixed.
“There was no feedback mechanism for obtaining views of relatives about the service.” from the report
- 01What work has been completed to make the fire doors close properly, and how is fire safety now being checked?
- 02What repairs have been made to the laundry room, including the flooring, broken tiles, wall and floor seals, and handwashing facilities?
- 03What action has been taken in response to the warning notices for premises and equipment and good governance?
- 04How do you now make sure audits identify environmental, maintenance and infection control risks?
- 05How are relatives’ views collected, and how are best-interest decisions recorded?
This began as a targeted inspection of health and safety concerns and widened to a focused inspection; it mainly examined Safe and Well-led, with infection prevention and control included under Safe. This explanation was written from the published report of 6 February 2024 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, April 2023
Rated Requires Improvement; inspectors found kind and consistent care, but medicines, infection control and quality checks were not always safe or effective.
This was an unannounced focused inspection on 28 February 2023. Two inspectors spoke with people, staff, relatives and a professional. They observed care and checked care records, medicines records, staff files and management records.
The home had enough staff and people appeared comfortable and supported. Staff knew people well, understood safeguarding, and helped people make choices. There were improvements in the kitchen, food safety, oxygen storage and checks on the building and equipment.
However, medicines were not always managed safely. Infection control arrangements still had shortfalls, including problems in the laundry area, worn surfaces and some staff wearing jewellery and nail varnish. Audits had not found the problems identified by inspectors.
The overall rating remains Requires Improvement. This home has had that rating for the last two consecutive inspections. The inspection only covered Safe and Well-led, so the other ratings were carried forward from the previous inspection.
Enough staff
Inspectors found enough staff to meet people's needs. Staff recruitment checks were completed, and an experienced core team knew people well.
“We found people were supported by enough staff to meet their needs.” from the report
Safeguarding and risk management
Staff understood how to protect people from abuse. Care records included reviewed risk assessments, and environmental and fire safety checks were in place.
“People were protected from the risk of harm because the service assessed, monitored and managed the risks associated with their care.” from the report
Kind and calm atmosphere
People appeared comfortable asking staff for help. Staff offered choices, listened to people and were described as supportive by relatives.
“During the inspection, we observed a relaxed, calm and inclusive atmosphere in the home.” from the report
Improvements since the last inspection
The kitchen and food safety had improved, and the home's food hygiene rating had risen to the highest score. Oxygen storage and some safety checks had also improved.
“The service's food hygiene rating had improved from a score of 1 to 5 (the highest rating).” from the report
Medicines were not always managed safely
seriousSome medicines were prepared too far in advance. PRN guidance was limited, pain relief was given regularly without recording whether it worked, and patch records were incomplete.
“We found no evidence that people had been harmed, however people were placed at risk by the failure to ensure the proper and safe management of medicines.” from the report
Infection control shortfalls
seriousThe laundry area and some building surfaces needed attention. Some sinks lacked nearby paper towels, most bins were not pedal operated, and some staff wore jewellery and nail varnish.
“This made it difficult for staff to consistently apply good infection control practices.” from the report
Quality checks did not find problems
seriousAudits were in place but had not identified the medicines and infection control concerns found during the inspection. There was also no formal system for gathering feedback from people, relatives and staff.
“A range of audits were in place, but these had not highlighted the shortfalls we identified relating to medicines and infection control.” from the report
- 01What changes have been made to PRN medicine protocols and records since the inspection?
- 02How do you now check that pain relief and transdermal patches are being used and recorded safely?
- 03What repairs or changes have been made in the laundry room and to worn or damaged surfaces?
- 04How are infection control practices, including staff jewellery, nail varnish, bins and paper towel supplies, now checked?
- 05How will you make sure audits identify problems, and how will relatives and staff give formal feedback?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 13 April 2023 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 Edgecumbe Lodge Care Home
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- February 2024Requires improvementcurrent ratingstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2021GoodSafe: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- November 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- October 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 13 August 2012.
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 £1,020 to £1,280 a week. 32 can care for a couple. 11 years' experience on average.
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