CQC report explained · a residential care home
What the CQC found at St Edmunds
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe, risks were generally assessed and managed, and medicines were given when needed. Inspectors found exposed hot pipework in an accessible area, but the registered manager acted immediately to make it safe.
- Effective?
- Good
- Staff were trained and understood people's health, dietary and communication needs. People received support from healthcare professionals and were involved in decisions about their care.
- Caring?
- Good
- Staff were observed to be kind, respectful and unhurried. People were involved in everyday choices and encouraged to remain as independent as possible.
- Responsive?
- Good
- Care plans gave staff guidance about people's wishes and preferences. Activities had increased since the previous inspection, and inspectors said earlier improvements to care planning had been completed.
- Well-led?
- Good
- The home had open leadership and regular checks on care quality. People, relatives and staff were encouraged to give feedback, and identified shortfalls were used to improve care.
What inspectors found, June 2019
St Edmunds was rated Good; inspectors found kind, person-centred care, with a hot pipework risk dealt with during the visit and some reports of waiting for help.
This was a planned inspection to check that the home remained Good. One inspector and an expert by experience visited on 30 May 2019. They spoke with eight people, two relatives, staff and healthcare professionals, and reviewed care and medicine records.
All five areas were rated Good. Inspectors found people were safe, treated with kindness and respect, supported to make choices, and given care that met their needs. Staff were trained, healthcare was well coordinated, medicines were managed safely and there were enough staff according to staff and most people spoken with.
There were two points to note. Inspectors found exposed, very hot pipework in an accessible area, which could have caused burns. The registered manager acted immediately. Two people also said they sometimes waited for help, so staffing levels were to be monitored closely. The Responsive rating improved to Good because earlier work on care planning, hobbies and interests had been completed.
Kind and respectful care
People and relatives described staff as kind and caring. Inspectors saw staff listening to people, respecting their wishes and protecting their privacy.
“Staff were kind and caring and respected people as individuals.” from the report
Personalised support
Care records reflected people's physical, mental and cultural needs. People were offered choices and supported to do things for themselves.
“People's care needs had been regularly reviewed to ensure the service could continue to meet them.” from the report
Health and medicines
Staff acted quickly when people became unwell and worked well with healthcare professionals. Inspectors found medicines were received, stored and given safely.
“People received their medicines when they needed them. The records we looked at confirmed this.” from the report
Open management
People, families and staff were listened to, and the home used audits, feedback and incidents to improve care.
“This demonstrated an open culture in the home.” from the report
Hot pipework
seriousAn accessible area contained exposed pipework that was very hot to touch. This created a risk of burns, although the registered manager acted immediately after inspectors raised it.
“This posed a risk of burns to people.” from the report
Waiting for assistance
needs fixingTwo people said they sometimes had to wait for help, with one reporting a wait of around 10 minutes. The registered manager agreed to monitor staffing levels closely.
“Sometimes I must wait for around 10 minutes and it can get quite uncomfortable.” from the report
- 01How was the exposed hot pipework made safe, and how do you now check for similar risks?
- 02How do you decide how many staff are needed on each shift, especially when people need help at the same time?
- 03What changes were made after people said they sometimes waited around 10 minutes for assistance?
- 04How will you plan activities around my relative's own hobbies, interests and communication needs?
- 05What progress has been made with the Six Steps Programme for end of life care?
This was a planned inspection of all five CQC questions, including the care and premises, and the report says the Responsive rating improved while the other ratings remained Good. This explanation was written from the published report of 26 June 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.
What inspectors found, December 2016
St Edmunds was rated Good overall; inspectors found safe, kind care, but activities and care records needed improvement.
The inspection was unannounced and took place on 12 and 14 October 2016. One inspector and an expert by experience spoke with people, visitors and staff. They reviewed four care plans and other records.
The home was rated Good for Safe, Effective, Caring and Well-led. People were treated kindly, medicines were managed safely, staff were trained, and health and eating needs were monitored.
Responsive was rated Requires Improvement. Activities were not regular or varied enough for everyone's interests. Some care plans and records were confusing or not updated promptly when people's needs changed.
Kind and respectful staff
People spoke positively about staff. Inspectors saw staff listening, offering choices and protecting people's dignity.
“The staff were kind, respectful and promoted people's independence and dignity.” from the report
Good health support
The home had regular contact with health professionals. Staff monitored people's health and looked for early signs of illness.
“This meant people needs were responded to in a timely manner.” from the report
Positive leadership culture
Inspectors found a strong senior team and good support for staff development. People and relatives were asked for feedback.
“There is a strong ethos and caring culture at this service.” from the report
Night staffing
needs fixingThere were two staff at night, while five people needed two staff to help with moving. Inspectors were concerned that other people might not receive help promptly during these tasks.
“There were two staff at night which through our experience is on the low side” from the report
Too few activities
needs fixingActivities did not take place every day and did not meet everyone's hobbies and interests. Some people were left isolated or had little to do.
“Overall we found that staffing levels within the service did not enable staff to adequately respond to people's individual needs in regards to their interests and hobbies.” from the report
Care records not always current
needs fixingSome records were difficult to follow and did not clearly show how changing needs were being managed. Inspectors found examples involving weight loss, diabetes, infections and constipation.
“Records did not always reflect a change in people's needs but we were confident that staff were responsive to people's needs.” from the report
Some people needed more encouragement at mealtimes
minorUpstairs, some people eating in their rooms had barely touched their meals and were not encouraged by staff to eat or join others.
“We saw a number of people had barely touched their meal and were not given encouragement by care staff” from the report
- 01How many staff are on duty overnight now, and how do you make sure someone can respond when two staff are helping a person to move?
- 02What regular activities are now available, including activities for people who prefer hobbies, gardening or time outside?
- 03How do you check that every care plan reflects a person's current needs after a hospital stay, weight loss or a change in independence?
- 04How do you monitor people's food, drink and bowel care when information is held in different records?
- 05Who is the registered manager now, and how is the management arrangement working after the recent changes?
This was an unannounced inspection covering all five quality questions, with visits on two days; inspectors spoke with 12 people, two visitors and eight staff and reviewed four care plans. This explanation was written from the published report of 20 December 2016 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 St Edmunds
2 rated inspections over 3 years: the service has held its Good rating throughout.
- June 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- September 2011
Registered with the Care Quality Commission on 9 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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