CQC report explained · a residential care home
What the CQC found at Edgehill Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, medicines were given safely, staffing was sufficient and infection control arrangements were effective.
- Effective?
- Good
- This area was not looked at during this focused inspection. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This area was not looked at during this focused inspection. Its previous rating was carried forward into the overall rating.
- Responsive?
- Requires improvement
- This area was not looked at during this focused inspection. Its previous rating was carried forward into the overall rating.
- Well-led?
- Good
- Inspectors found effective audits and action plans, an open culture and leadership that kept people at the centre of the service.
What inspectors found, March 2021
Rated Good; inspectors found improved safety, medicines management and leadership after the previous Requires Improvement rating.
This was an announced focused inspection on 3 March 2021. Inspectors looked mainly at Safe and Well-led, including infection control during coronavirus. They spoke with people, relatives and staff, and reviewed care, medicines, recruitment and quality records.
The home was rated Good for Safe and Good for Well-led. Inspectors found that risks were assessed, medicines were managed safely, staffing levels met people's needs and infection control systems were effective. The home was clean and staff used protective equipment in line with guidance.
The previous inspection, published in November 2020, had rated the home Requires Improvement and found several legal breaches. At this inspection, inspectors found enough improvement and said the home was no longer in breach of those regulations.
The overall Good rating includes ratings carried over from the previous comprehensive inspection for areas not examined during this visit.
Safer medicines and risk checks
Care plans were kept up to date and included guidance about risks such as falls, choking and pressure damage. Inspectors found that medicines were given as prescribed.
“Medicines were managed safely. Systems ensured people received their medicines as prescribed.” from the report
Enough staff
People and staff told inspectors there were enough staff. Inspectors found that people received help promptly and staff were not rushed.
“There were enough staff and people received support in a timely manner from staff who were not rushed.” from the report
Infection control
The home was clean and inspectors were assured about protective equipment, testing, social distancing and arrangements for preventing or managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Improved management
The home had better auditing and action plans to identify and address problems. Relatives gave positive feedback about the open culture.
“There were effective systems in place to enable the quality of the service to be monitored and improved.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you now check that medicines continue to be given safely and as prescribed?
- 02How do you monitor staffing levels and response times when people's needs change?
- 03What do your current audits show about risks such as falls, choking and pressure damage?
- 04How do you keep infection prevention arrangements up to date?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led, including infection control; the other key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 19 March 2021 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, November 2020
Edgehill Care Home is rated Requires Improvement; inspectors found problems with medicines, risk records and quality checks, despite kind care and improved leadership.
Inspectors carried out a focused inspection on 12 August 2020. They checked whether earlier warning notices about safe care and treatment and good governance had been met. They reviewed care and medicines records, spoke with people, relatives, staff and a health professional, and checked infection control.
The home was not always safe. One person's emergency medicine was out of date. Risks were not always assessed or clearly recorded, and medicines records and care plans were sometimes incomplete or inconsistent. Inspectors said there was no evidence people had been harmed, but these failures increased the risk of harm.
The home was not always well-led. Audits had found some problems, but action was not always taken promptly and checks had missed other concerns. People generally said they felt safe, staff had time for them, infection control was effective, and relatives and staff spoke positively about the new home manager. The overall rating remained Requires Improvement.
Enough attentive staff
People said there were enough staff, and inspectors saw staff spending time with people and responding to their needs.
“Throughout the inspection staff were attentive and had time to speak with people.” from the report
Infection control
Inspectors found suitable COVID-19 precautions, enough protective equipment and a clean home.
“The service was clean and free from malodours. There were cleaning schedules in place to ensure all areas of the service were kept clean.” from the report
Positive relationships
People and relatives said they felt safe and were positive about the care and support they received.
“People and relatives told us people were safe in the service.” from the report
Improved leadership culture
The new home manager was described as approachable, and staff reported improved morale and feeling listened to.
“There was an open culture and staff were complimentary about the improved staff morale that had been achieved with the support of the home manager.” from the report
Out-of-date emergency medicine
seriousAn emergency medicine prescribed for one person was out of date. This was a breach of the safe care and treatment regulation and could have put the person at risk.
“One person was prescribed a medicine to be administered in an emergency situation. This medicine was out of date.” from the report
Risks and care plans not reliable
seriousSome risks were not assessed, and care plans gave conflicting or missing information. Staff might not have had clear instructions about how to manage people's conditions.
“Risks to people were not always assessed and managed.” from the report
Medicines records incomplete
seriousMedicine administration records were not always accurate or signed as required. Allergy information was also inconsistent between records.
“Handwritten entries on medicine administration records (MAR) did not always contain accurate information and were not always signed by two staff as required.” from the report
Audits did not lead to prompt action
seriousChecks had identified some problems, but actions were not completed quickly and other issues were missed. This was a continued breach of good governance.
“Audits carried out had identified some issues found during the inspection. However, action had not been taken in a timely manner to address these issues.” from the report
- 01What has been done to make sure all emergency medicines are in date, and how often are they checked?
- 02How do you make sure new residents have complete risk assessments and care plans promptly after moving in?
- 03How are medicines administration records checked for accuracy and the required signatures?
- 04Who is responsible for each action found in an audit, and how do you check that it is completed on time?
- 05What are the current ratings for Effective, Caring and Responsive, which were not assessed in this focused inspection?
This was a focused inspection of Safe and Well-led, including infection control; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 21 November 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 Edgehill Care Home
6 rated inspections over 5 years: the service has held its Good rating throughout.
- March 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- November 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2020Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- June 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- September 2011
Registered with the Care Quality Commission on 23 September 2011.
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 £990 to £1,280 a week. 34 can care for a couple. 12 years' experience on average.
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