CQC report explained · a nursing home
What the CQC found at Edwin House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found some unclean bedrooms and weaknesses in records for as-needed medicines, but no evidence that people had been harmed.
- Effective?
- Good
- This key question was not inspected during this focused inspection. The overall rating used ratings from the previous inspection where questions were not inspected.
- Caring?
- Good
- This key question was not inspected during this focused inspection. The overall rating used ratings from the previous inspection where questions were not inspected.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. The overall rating used ratings from the previous inspection where questions were not inspected.
- Well-led?
- Good
- Management and quality checks had improved since the previous inspection. Managers understood their roles, acted on feedback and took immediate action when inspectors identified medicine record problems.
What inspectors found, November 2023
Rated Good; inspectors found safe, supportive care, but some bedrooms posed an infection risk and some as-needed medicines records needed improvement.
This was an unannounced focused inspection on 5 and 6 October 2023. Inspectors spoke with people using the home, staff, managers and outside professionals. They reviewed care, medicine and staff records, along with management information.
The home was rated Good for Safe and Well-led. People told inspectors they felt safe and had enough staff support. Risks were assessed, safeguarding concerns were acted on, and the home supported people with programmes to reduce or end substance misuse.
Inspectors found some bedrooms at Edwin House were unclean and posed an infection control risk. Staff had repeatedly offered support to clean them, and the people concerned had capacity to make their own decisions. Some records for as-needed medicines were missing or lacked detail, but this was corrected during the inspection and no harm was found.
This was a focused inspection of Safe and Well-led only. The overall Good rating remained based partly on the previous inspection, published in September 2019. Well-led improved from Requires Improvement to Good.
People felt safe
People told inspectors they felt safe and staff knew how to recognise and report abuse. Safeguarding incidents were recorded, reviewed and referred to the relevant authorities.
“People were protected from the risk of abuse and neglect.” from the report
Enough trained staff
Inspectors found enough suitably skilled, trained and experienced staff to keep people safe. Recruitment checks were completed, although recruitment was still under way.
“There were enough suitably skilled, trained, and experienced staff to keep people safe.” from the report
Improved management
Management systems had improved since the previous inspection. Managers worked together and used action plans and quality checks to drive improvement.
“At this inspection we found improvements had been made.” from the report
Respectful staff
People said they did not feel judged and felt supported to improve their lives. Inspectors observed positive interactions and found staff showed empathy.
“People told us they did not feel judged by staff, felt supported to gain the skills needed to address their addiction and were encouraged to improve their lives.” from the report
Unclean bedrooms
needs fixingSome bedrooms at Edwin House were unclean and posed an infection control risk. Staff had offered advice and help, and continued support was planned.
“We found some bedrooms at Edwin House building did pose an infection control risk.” from the report
As-needed medicine records
needs fixingSome instructions for as-needed medicines were missing or not detailed enough. This could have led to inconsistent administration, although inspectors found no evidence of harm and the issue was addressed during the inspection.
“We found some of these protocols at Edwin House were either not in place or lacked detail and could lead to the risk of inconsistent administration.” from the report
Use of agency staff
minorAgency staff were being used for some shifts at Edwin House. Recruitment was continuing, with plans to address this.
“Agency staff were currently used to cover some staffing shifts at Edwin House.” from the report
- 01Have all the bedrooms identified as an infection control risk been cleaned, and how are they checked now?
- 02Are detailed instructions now in place for every as-needed medicine?
- 03Has the medicines coordinator been appointed, and how does this role check medicine safety?
- 04How much agency staff is currently being used at Edwin House, and what is the timetable for reducing it?
- 05What were the ratings 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 carried over from the previous inspection published on 19 September 2019. This explanation was written from the published report of 10 November 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.
What inspectors found, September 2019
Rated Good overall; inspectors found safe, caring and responsive support, but the home’s leadership required improvement.
This was the first full, comprehensive inspection since the service registered. It was unannounced and took place on 28 August 2019. Inspectors spoke with four people, 10 staff members and the registered manager. They also checked care and medicines records, staff files and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found the environment safe and clean, medicines managed safely, and staff trained to support people. People were treated with dignity, involved in decisions and supported with food, activities, healthcare and recovery services.
Well-led was rated Requires Improvement. The home had experienced problems after moving to larger premises and growing. Improvements were being put in place with support from the local authority and other organisations, but inspectors said these changes needed to become established. The overall rating was Good.
Safe medicines systems
Medicines were managed, given and disposed of safely. Electronic systems linked to the pharmacy helped staff monitor medicines and stock.
“Medicines systems were electronic and linked to the pharmacy.” from the report
Respectful care
People described staff positively. Inspectors saw staff being kind, listening to people and respecting privacy, dignity and personal choices.
“Staff are always polite and respectful, they knock before coming into my room, they help me when I need it” from the report
Activities and recovery support
People could take part in activities such as gym sessions, bowls, quizzes, cooking and pool tournaments. The home also worked with specialist recovery services.
“The service supported people to attend a gym, they had bowls sessions, quizzes, cooking and pool tournaments.” from the report
Choice and involvement
People were involved in support planning and regular meetings. They could express their preferences about care, food and activities.
“People were involved in their support planning and were able to express their preferences in the way they liked to receive support.” from the report
Risk information was spread out
needs fixingRisk assessments were kept in different places. Inspectors said this made it difficult to find current information and keep track of updates, particularly for new staff.
“However, these were kept in different places, some in a file, some with support plans and others in the kitchen.” from the report
Initial assessments were too simple
needs fixingThe first assessment for people referred to the home did not look at all their needs. Inspectors said it was not suitable for deciding whether the home could meet those needs.
“However, the initial assessment of people referred to the service was not holistic and formed a simplistic overview.” from the report
Leadership oversight needed to improve
needs fixingThe provider’s internal monitoring did not identify problems early enough. Improvements had started, but inspectors said they still needed to become established.
“The problems with the service should have been picked up by internal quality monitoring.” from the report
Some end of life plans were incomplete
minorEnd of life planning had started for everyone, but not all plans were finished at the time of the inspection.
“Not all of the planning had been completed but it had all been started so that everyone had an end of life plan in place.” from the report
- 01How are risk assessments now kept together so staff can quickly find the current information?
- 02How do you assess a new referral’s full needs before deciding whether the home is suitable?
- 03What changes were made to management and quality checks after this inspection, and how do you know they are working?
- 04Have all end of life care plans now been completed and reviewed with the people concerned?
- 05How are people supported to take part in recovery programmes and the activities they choose?
This was the first full comprehensive inspection since registration and covered all five CQC questions. This explanation was written from the published report of 19 September 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 Edwin House
2 rated inspections over 4 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2019GoodSafe: GoodWell-led: Requires improvement
- February 2018
Registered with the Care Quality Commission on 12 February 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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