CQC report explained · a residential care home
What the CQC found at Edwina Place
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People said they felt safe and staff understood safeguarding and personal risks. However, records for premises checks and medicines were incomplete or not consistently maintained.
- Effective?
- Good
- People received support with healthcare, nutrition and decision-making. Staff had induction, supervision and training, although some staff still needed training refreshers for particular risks.
- Caring?
- Good
- People and relatives described staff as kind, caring and respectful. Staff supported privacy, dignity, independence and personal choice.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People were supported with communication, relationships, activities and complaints, although some people wanted more group activities.
- Well-led?
- Requires improvement
- The manager and staff were approachable and worked positively with people. However, governance systems did not consistently identify problems or provide a full and accurate overview of quality, safety and legal compliance.
What inspectors found, July 2023
Edwina Place was rated Requires Improvement; inspectors found kind, personalised care but weaknesses in medicines records, premises checks and quality oversight.
This was the home’s first inspection. It was unannounced and took place on 9 and 13 March 2023. Inspectors spoke with people, relatives, staff and professionals. They observed care and checked records, including care plans, medicines, accidents, complaints and premises checks.
People told inspectors they felt safe. Staff understood safeguarding and individual risks. However, records for premises checks and medicines were not always complete. Some medicines protocols and administration records lacked important information, and some temperature and stock checks were not completed as required.
Care was rated Good in Effective, Caring and Responsive. People were treated with kindness and respect, involved in decisions, supported with healthcare and helped to follow their interests. The home was rated Requires Improvement for Safe and Well-led because its monitoring systems did not consistently identify or manage risks.
The provider breached Regulation 17 on good governance. CQC asked for an action plan and said it would work with the provider and local authority to monitor progress.
People felt safe
People and relatives told inspectors they felt safe with staff. Staff knew how to recognise and report abuse.
“People told us they felt safe at the service and with the staff” from the report
Kind and respectful care
Inspectors saw positive interactions. Staff respected people’s dignity, privacy, choices and independence.
“The service ensured people were treated with kindness and respect.” from the report
Personalised support
Care records described people’s histories, preferences and needs. Staff used this information to build relationships and support individual goals.
“People's care records contained detailed descriptions of people's life histories and preferences.” from the report
Support with health
People were helped to attend health checks and appointments. Staff worked with health and social care professionals when needed.
“People had regular health reviews and hospital assessments that supported their health and social care” from the report
Weak quality checks
seriousThe home’s monitoring systems did not consistently identify or manage risks. This included gaps in records and incomplete evidence about premises checks.
“The provider did not always follow their quality assurance systems effectively to assess, monitor and mitigate any risks” from the report
Medicines records
seriousSome medicines protocols and administration records lacked required information. Temperature checks and stock checks were also not consistently completed.
“The completion of some of the medicine management records needed reviewing and improving according to provider's policy and current best practice guidance.” from the report
Recruitment information
needs fixingThree staff files did not contain all the information needed to show that employment histories and reasons for leaving had been checked.
“Staff files did not always contain required information to demonstrate safety checks had been completed.” from the report
Training and staffing mix
needs fixingSome staff had not completed or refreshed training linked to people’s specific needs and risks. The provider was asked to review whether the right mix of skilled staff was on duty.
“We recommend the provider seeks advice from a reputable source to review their system that ensured there was a right mix of skilled, trained, knowledgeable staff on duty to keep people safe.” from the report
More activities wanted
minorSome people wanted more activities in the home. Inspectors also said daily records could give more detail about activities offered and alternatives when people declined.
“A few people told us they would like to have more in-house activities to get everyone together as it was not that often.” from the report
- 01What has been changed to make sure medicines administration records, PRN protocols, temperature checks and stock checks are complete every time?
- 02Can you show us recent records proving that premises safety checks and legionella actions are being completed and followed up?
- 03How have you checked that all staff files contain the required employment and conduct information before staff work with residents?
- 04How do you make sure enough staff with the right training are on duty for people’s specific needs and risks?
- 05What activities are now offered in the home, and how are people’s choices or refusals recorded?
This was an unannounced first inspection that looked at all five key questions, including infection prevention and control; no previous ratings were carried over. This explanation was written from the published report of 12 July 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 Edwina Place
Each visit the CQC has published, newest first, back to the day the home was registered.
- July 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2021
Registered with the Care Quality Commission on 13 May 2021.
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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