CQC report explained · a residential care home
What the CQC found at St Edwards Close
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2022
St Edwards Close was inspected but not rated; inspectors found good infection-control practice but several procedures needed improvement.
This was an announced, targeted inspection on 23 February 2022. It looked at infection prevention and control, visiting arrangements and COVID-19-related staffing pressures. Seven people were living in the home, which can support up to eight people.
Inspectors found staff had infection-control training, wore face masks and used full protective equipment for personal care. Visiting, testing and contact with family and friends were in place in line with the guidance described in the report.
There were also shortfalls. Checks were not always completed for one visitor, the admissions policy was out of date, used protective equipment was not always bagged, and cleaning records and infection-control audits were not strong enough. The provider said it fixed these issues after the inspection.
The home was inspected but not rated. This means the report does not give a Good, Requires improvement or Inadequate rating for the service.
Staff infection-control training
Staff had training in infection prevention and control, including using protective equipment and hand washing. They wore face masks during the inspection and used full protective equipment for personal care.
“Staff had received infection prevention and control training, including how to put on and take off personal protective equipment (PPE) and hand washing.” from the report
Family contact and visiting
Visiting arrangements followed the government guidance described in the report. People could also keep in touch with family and friends by video and telephone.
“The visiting arrangements for the service were in line with government guidance.” from the report
Testing and vaccination
People and staff were tested in line with the guidance described in the report. Staff were vaccinated, and visiting professionals had their vaccination status checked.
“People and staff were tested for COVID-19 in line with government guidance and all staff had been vaccinated.” from the report
Staffing arrangements
The provider said it had enough staff and arrangements to manage staffing difficulties linked to COVID-19.
“The service had enough staff and had measures in place to deal with any staffing difficulties arising from COVID-19.” from the report
Visitor checks were not always completed
needs fixingThe temperature and negative test checks were not always completed for a gardener entering the building. The provider said it had started taking and recording these checks after the inspection.
“However, staff had not always taken the gardener's temperature or checked whether they had taken a LFT before they entered the building.” from the report
Out-of-date admissions policy
needs fixingThe admissions policy did not include COVID-19 procedures. The provider said it updated the policy after the inspection.
“The provider's admissions policy was not up to date and did not include COVID-19 procedures.” from the report
Used protective equipment
seriousUsed protective equipment was taken from people's rooms to clinical waste bins without being put in a bag first. The provider said this changed after the inspection.
“However, staff were taking used PPE from people's rooms through the building to clinical waste bins without putting it in a bag.” from the report
Cleaning records and storage
needs fixingThe cleaning schedule was not strong enough and was not always completed. Mops and buckets were not stored securely, although the provider said it introduced a new schedule and secured the storage cupboard.
“The home was clean and tidy. However, the cleaning schedule in place was not rigorous enough to prevent and control infection and had not always been completed.” from the report
Infection-control audits
needs fixingThe audits did not check the cleaning schedules and had not identified the problems found by inspectors. The provider said it took immediate action to address them.
“The provider's infection prevention and control (IPC) audits did not include an audit of the cleaning schedules.” from the report
- 01Can you show how you now check temperatures and negative tests for every visitor, including contractors and gardeners?
- 02Can you explain what changed in the admissions policy after the inspection?
- 03How are used protective equipment and clinical waste handled now?
- 04How often are cleaning tasks completed and checked, and can we see the records?
- 05Do your infection-control audits now include cleaning schedules and the issues found at this inspection?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated and the other key questions were not assessed. This explanation was written from the published report of 15 April 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, April 2020
St Edwards Close was rated Good; inspectors found kind, safe and personalised care, with improvements since the previous inspection.
Inspectors visited on 10 and 27 February 2020. The first visit was unannounced. They spoke with people living there, staff, relatives and health professionals. They observed care, medicines and meals, and checked care records, staff files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found suitable staffing, safe medicines processes, detailed care plans and kind support. People were helped to make choices and maintain their health and relationships.
The previous inspection rated the home Requires Improvement and found breaches about hot water safety and the condition of bathrooms. Inspectors found these problems had been addressed, and the home was no longer in breach of regulations. The report says the home met the characteristics of a Good rating in all areas.
Kind and respectful care
Relatives spoke positively about the staff. Inspectors also saw staff spending time with people, encouraging activities and offering choices.
“We observed staff treated people with kindness through the inspection, spending time interacting with them and encouraging them with their activities.” from the report
Personalised support
Care plans included people's needs, preferences and communication methods. Relatives were involved in reviews of care.
“Care plans set out detailed information about people's preferences, needs and the tasks staff were expected to carry out to meet people's needs.” from the report
Safe medicines practice
Staff who gave medicines had completed training. Records had no unexplained gaps, and stored medicines matched the recorded amounts.
“Medicines administration records [MARs] were completed as required. There were no unexplained gaps in the records.” from the report
Improvements after the last inspection
The provider acted on the previous findings. Hot water checks and safety controls were introduced, and the bathrooms were refurbished.
“At this inspection we found all the bathrooms were completely refurbished and redecorated to a high standard” from the report
Stronger quality checks
Inspectors found that audits had become wider and more effective. They covered areas including medicines, care records, staffing, premises and incidents.
“Since the last inspection they had reviewed the range and effectiveness of their auditing systems and actions were taken when shortfalls or areas for improvement were identified.” from the report
No registered manager at the inspection
needs fixingThe previous registered manager had left shortly before the inspection. The deputy manager was acting as manager with support from regional managers.
“The service did not have a manager who was registered with the CQC, the previous registered manager left in January 2020.” from the report
End of life arrangements were still being developed
minorThe home was not providing end of life care to anyone at the time. Inspectors were told that a policy and procedure were still being prepared.
“However, they said they were developing an appropriate policy and procedure with a local hospice to put in place in the near future.” from the report
- 01Who is currently responsible for managing the home, and has the manager registered with the CQC?
- 02What arrangements are now in place for end of life care and support?
- 03How often are hot water temperatures checked, and how are the checks recorded?
- 04What extra checks are now used to prevent missed medicine doses?
- 05How will my relative's communication preferences and choices be recorded in their care plan?
This was a planned inspection covering all five key questions, including care, safety, the premises and how the home was managed. This explanation was written from the published report of 4 April 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 Edwards Close
3 rated inspections over 4 years: the service has held its Good rating throughout.
- April 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- April 2020Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
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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