CQC report explained · a residential care home
What the CQC found at St Edmunds Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors were assured about testing, protective equipment, admissions, visiting safety and the prevention of infection outbreaks. They were only somewhat assured that the infection-control policy was up to date, and found that visiting care plans needed more detail.
- Effective?
- Requires improvement
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Requires improvement
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, March 2022
Inspected but not rated; inspectors found good COVID-19 infection control, but some policies and visiting records needed updating.
This was a targeted inspection on 8 February 2022. Inspectors looked at infection prevention and control, visiting arrangements and the effect of COVID-19 staffing pressures. The visit was announced 24 hours beforehand.
Inspectors found that staff and visitors followed government guidance. There was enough protective equipment, staff used it properly, and staff and residents were tested regularly. Inspectors also saw positive interactions between staff and residents.
The home was not given an overall quality rating or a rating for safety. Inspectors were somewhat assured that the infection-control policy was up to date, because some parts needed more detail. Visiting care plans also needed more information about people's preferences and essential care givers.
Infection-control checks
The home carried out checks on visitors and followed the government's COVID-19 guidance to reduce infection risks.
“The provider ensured current government guidelines in relation to COVID-19 were being followed by staff and visitors to reduce the risk of infection to people living at the home.” from the report
Protective equipment
Inspectors saw enough aprons, gloves and masks, and staff were using them appropriately. Staff had also completed relevant infection-control training.
“There was enough PPE such as aprons, gloves and masks. Staff were wearing this appropriately when we visited.” from the report
Regular testing
Residents and staff were tested regularly. Residents could choose to carry out their own tests.
“Staff and people were tested regularly for COVID-19. People were offered the choice to self-administer the tests if this was their preference.” from the report
Support for wellbeing
Inspectors saw positive interactions between staff and residents during the pandemic.
“Staff had worked as a team to help promote people's wellbeing throughout the pandemic. We observed lots of positive interactions between staff and people.” from the report
Policy needed updating
needs fixingSome parts of the infection-prevention and control policy did not contain enough detail about the latest guidance. The manager was reviewing and updating the policies.
“We were somewhat assured that the provider's infection prevention and control policy was up to date.” from the report
Visiting records needed more detail
needs fixingVisiting care plans did not clearly record people's preferences or whether an essential care giver was in place. One relative also felt communication about visiting arrangements could be better.
“Visiting care plans needed additional detail to ensure people's preferences were known, and whether there was an essential care giver in place.” from the report
- 01Has the infection prevention and control policy now been fully updated, and what extra detail was added?
- 02How are residents' visiting preferences recorded and kept up to date?
- 03Does each resident who wants one have an essential care giver, and how would visits continue during an outbreak?
- 04How are families told about changes to visiting arrangements?
- 05What staffing pressures is the home experiencing now, and how are these affecting residents?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it did not provide a full quality rating. This explanation was written from the published report of 3 March 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, January 2020
St Edmunds Residential Home was rated Requires Improvement; inspectors found kind care but gaps in risk records, care documentation and oversight.
This was an unannounced inspection on 26 November 2019. Inspectors spoke with five people, two relatives, six staff members and one health professional. They reviewed care, medicine and staff records, as well as management information.
The home was rated Requires Improvement overall. Safe, Effective, Responsive and Well-led were also rated Requires Improvement. Caring was rated Good. The overall rating and four question ratings had fallen from Good at the previous inspection.
People said they felt safe and that staff were kind and caring. Medicines were generally managed safely, the home was clean, and people were supported to make choices. However, risk information, nutrition records, mental capacity records and care plans were not always accurate or detailed enough.
The home had systems to monitor quality, but these had not found all the problems inspectors identified. The provider was asked for an action plan, and CQC said it would monitor progress and return under its re-inspection programme.
Kind and respectful staff
People and relatives described staff as caring. Inspectors saw a relaxed and friendly home where people were treated with dignity.
“Staff treated people with kindness and respect. One person told us, "The staff are lovely, I get on well with them all.” from the report
People felt safe
People said they felt safe with staff. Staff knew how to recognise and report possible abuse.
“People told us they felt safe in the home and with the staff team.” from the report
Medicines generally managed safely
Medicine administration records had no gaps, and guidance was available for medicines given when needed. There were also records of allergies, photographs and people's preferences.
“People's medicines were managed safely. The medicines administration records (MAR) had no gaps in recording.” from the report
Clean environment
The building was regularly cleaned and visibly clean. Staff had cleaning materials and protective equipment.
“The building was cleaned regularly, and all areas were visibly clean and fresh.” from the report
Choice and involvement
Staff offered choices during daily care and meals. People and relatives could give feedback through meetings and questionnaires.
“Staff involved people in decisions throughout the day. They asked them what they would like to do and where they would like to spend their time.” from the report
Risk information was unclear
seriousSome care plans did not explain risks or the action staff should take. This included choking, pressure mats and moving and handling.
“For example, where people were at risk of choking, there was no guidance for staff on what action to take in the event of a choking incident.” from the report
Food and drink records were not clear
needs fixingRecords did not always show what people had actually eaten or drunk. This could make it harder for health professionals to decide on treatment for people at risk of losing weight.
“It wasn't clear what people had consumed to evidence if people were having additional calories to increase their weight.” from the report
Care and consent records were inaccurate
needs fixingSome care plans and mental capacity records contained incorrect, missing or contradictory information. Inspectors also found inaccurate information about deprivation of liberty safeguards.
“People's records made reference to their ability to make decisions about their care, and if they lacked capacity, mental capacity assessments were completed.” from the report
Weekend activities were limited
minorPeople enjoyed activities during the week but some said they were bored at weekends. CQC recommended that the home review activity provision, including at weekends.
“There needs to be more at the weekends, but they do their best.” from the report
Management checks missed problems
seriousAudits and care plan reviews had not identified all the issues inspectors found. More regular monitoring was needed to make sure records reflected people's current needs.
“The inspection process highlighted some issues which audit systems had failed to identify, such as the documentation of dietary intake.” from the report
Recruitment checks needed strengthening
needs fixingSome employment history and offence information had not been properly explored or risk assessed before staff were appointed.
“Pre-employment checks were in place, but were not always sufficiently robust.” from the report
- 01What changes have been made to ensure choking, pressure mat and moving and handling risks are clearly recorded?
- 02How do you now record exactly what people at risk of losing weight eat and drink, and how is this shared with dieticians?
- 03Have all mental capacity and deprivation of liberty records been corrected and checked?
- 04What activities are now available at weekends for people with different interests and support needs?
- 05How do managers check that care plans and daily records are accurate and up to date?
This was an unannounced planned inspection covering all five key questions; the previous inspection had rated the service Good in May 2017. This explanation was written from the published report of 24 January 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 St Edmunds Residential Home
3 rated inspections over 3 years: the service has improved, from Inadequate to Requires improvement.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- January 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2017Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2016InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2015
Registered with the Care Quality Commission on 30 November 2015.
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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