CQC report explained · a residential care home
What the CQC found at Edwin Therapeutic Unit
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staffing, medicines and infection control had improved, but one young person's privacy restriction had not been properly reviewed. Risk records contradicted the practice of constant supervision, and the home remained in breach of safeguarding requirements.
- Effective?
- Requires improvement
- Staff had relevant training and people were supported with healthcare, food and independence. However, the home did not consistently apply the Mental Capacity Act or meet the conditions of a Deprivation of Liberty Safeguard.
- Caring?
- Requires improvement
- Staff were kind, warm and respectful, and young people were involved in choices about their care. However, constant supervision without a proper review did not protect one young person's privacy and human rights.
- Responsive?
- Good
- Care plans were personalised and reflected young people's needs, preferences and goals. Young people could take part in activities, develop skills, raise concerns and receive information in ways they could understand.
- Well-led?
- Requires improvement
- The new manager had improved communication and the culture of the home. However, quality checks were not robust enough to identify conflicting records, missing updates and actions needed for improvement.
What inspectors found, October 2022
Rated Requires Improvement; the home has improved since its previous Inadequate rating, but privacy restrictions, legal safeguards and quality checks were still not managed properly.
This was an unannounced follow-up inspection on 19 May 2022. Two inspectors spoke with the one young person living at the home and three staff members. They reviewed care records, risk assessments, medicines records, staff training, rotas, incidents and management checks.
The home had improved from its previous Inadequate rating. Medicines, infection control, staff training, complaints, care planning and risk assessment had improved. Staff were described as kind and supportive, and young people were helped to take part in activities and work towards their goals.
However, one young person was supervised constantly, including at night, without evidence that this restriction of privacy had been reviewed as the least restrictive option. Records also gave conflicting instructions about the level of supervision. The home did not understand or follow all the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards.
The overall rating was Requires Improvement. Safe, Effective, Caring and Well-led were also rated Requires Improvement. Responsive was rated Good. The home remained in breach of regulations about safeguarding and governance, and was newly found in breach of the regulation about consent.
Improved medicines safety
Medicines systems had improved after an external pharmacist's review. There were safer storage arrangements, staff competency checks, regular audits and stock counts.
“Medicines management had been assessed by an external pharmacist.” from the report
Kind and supportive staff
Young people said staff were kind and caring. Inspectors saw staff showing warmth, respect and genuine interest in a young person's wellbeing.
“Staff members showed warmth and respect when interacting with young people.” from the report
Personalised activities and goals
Young people were supported to build independence, pursue interests, try new activities and work towards education and employment goals.
“Staff provided people with personalised and co-ordinated support in line with their communication and support plans.” from the report
Positive culture
The new manager had helped create better communication and a more supportive culture. Staff and professionals reported positive changes in how the home was run.
“The new registered manager had worked hard to change the culture of the service” from the report
Privacy restriction not reviewed
seriousOne young person was supervised constantly during the day and night. The home had not shown that this restriction had been reviewed to find a less restrictive option, despite a requirement linked to the person's Deprivation of Liberty Safeguard.
“There was no evidence this restriction of the young person's privacy had been reviewed to ensure it was the least restrictive” from the report
Mental Capacity Act not followed
seriousThe home did not understand all its responsibilities under the Mental Capacity Act and Deprivation of Liberty Safeguards. Capacity had not always been assessed for specific decisions, so it was unclear whether decisions were made lawfully and in the person's best interests.
“The provider had failed to act in accordance with the principles of the MCA 2005 and DoLS.” from the report
Quality checks lacked strength
seriousManagement checks had not identified or acted on conflicting instructions in records. Some improvement actions were not recorded and monitored, so the home could not show that changes were being sustained.
“Quality monitoring systems were being developed but continued to lack robustness.” from the report
Infection control equipment issue
minorThe washing machine was not mounted on an impervious stand. Inspectors identified this as an infection hazard and an area for improvement.
“However, the washing machine was not mounted on a stand constructed of an impervious material.” from the report
- 01How is constant supervision reviewed, and what steps are being taken to reduce this restriction on privacy?
- 02How do you check that Deprivation of Liberty Safeguard conditions are understood and followed?
- 03How are Mental Capacity Act assessments completed for specific decisions when a young person's capacity fluctuates?
- 04How do you make sure care plans, risk assessments and staff practice give the same instructions?
- 05What action has been taken about the washing machine and how is this checked?
This was an unannounced follow-up inspection after an earlier Inadequate rating, covering all five key questions and infection prevention and control. This explanation was written from the published report of 15 October 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 2021
Edwin Therapeutic Unit is rated Inadequate and in special measures; inspectors found serious risks in medicines, safeguarding, staffing and management.
This was an unannounced comprehensive inspection on 12 October 2021. Two inspectors reviewed care records, medicines, risk assessments, staff training, rotas, incidents, complaints and management checks. They spoke with staff, a relative and social care professionals.
The home was not consistently safe. Medicines were stored and recorded unsafely, risk assessments were not always clear or up to date, and fire doors did not close properly until action was taken after the inspection. Infection control arrangements were also not reliable.
Inspectors found that young people were not always treated with dignity or supported in a person-centred way. A punitive reward system was used, private information was shared, complaints were not properly followed up, and high staff turnover made support and relationships inconsistent.
The overall rating was Inadequate. The listed ratings were Inadequate for Safe, Effective, Caring and Well-led, and Requires Improvement for Responsive. The home was placed in special measures because significant improvement was needed.
Recruitment checks
The home completed checks before staff started work, including references, employment history, right to work and DBS checks.
“Appropriate checks were carried out on potential staff which included obtaining a person's work references, full employment history, right to work in the UK and a Disclosure and Barring Service (DBS) check.” from the report
Access to healthcare
Young people were supported to attend health and mental health appointments, and records of these visits were available to staff.
“Young people were supported to access health care and mental health care appointments.” from the report
Communication support
The home used pictures and alternative communication methods to help some young people understand key information.
“Key Information was available in PECS, so young people could understand its content.” from the report
Support with activities and relationships
Some young people were supported to take part in activities, education or employment, and to keep in touch with family and friends.
“They were supported to maintain and develop relationships with people who were important to them such as family and friends.” from the report
Unsafe medicines management
seriousMedicines were not securely stored, stock records did not match, and there were gaps in records for medicines taken when needed or during social leave. Inspectors said this created a risk of serious harm.
“The management of medicines had deteriorated which put young people at risk of serious harm.” from the report
Risks and fire safety
seriousRisk guidance was not always clear or updated after incidents. Three fire doors did not close properly, and the fire service was contacted.
“At the inspection three fires doors did not close properly.” from the report
Safeguarding failures
seriousThe home did not consistently protect young people from physical or emotional harm, and managers could not show that safeguarding procedures had been followed properly.
“The provider had failed to ensure there were effective systems to protect people from the risk of abuse.” from the report
Dignity and privacy
seriousA young person was blamed for an event, causing anxiety, and private information about young people and staff was shared with others.
“Young people were not always treated well and with dignity and respect.” from the report
Weak management oversight
seriousQuality checks had not identified or corrected earlier problems. Managers did not have full oversight, and complaints and incidents were not used reliably to improve the service.
“Quality monitoring systems continued to be ineffective and lacked the robustness to identify shortfalls and drive continuous improvement in the service.” from the report
- 01What has changed since the inspection to make sure all medicines, especially higher-risk medicines, are securely stored and accurately recorded?
- 02How are risk assessments updated after incidents, and what clear guidance do staff now have about using force and responding to self-harm risks?
- 03What training and regular supervision has every member of staff received in positive behaviour support, mental capacity, safeguarding and first aid?
- 04How are complaints now recorded, investigated and checked to make sure young people's concerns lead to action?
- 05How will the home provide stable keyworker relationships and consistent support despite the previous high staff turnover?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control, premises and care provided. This explanation was written from the published report of 11 December 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.
Every inspection of Edwin Therapeutic Unit
7 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- December 2021Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- April 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2017Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015
Report published without a new overall rating.
- October 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- May 2013
Registered with the Care Quality Commission on 3 May 2013.
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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