We carried out a review of the data available to us about Edgehill Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Edgehill Care Home, you can give feedback on this service.
Edgehill Care Home is a residential care home providing personal care to 36 people aged 65
and over at the time of the inspection.
Edgehill Care Home can accommodate up to 60 people in one building which is on one floor. The service supports people living with dementia.
People’s experience of using this service and what we found
Improvements had been made to the service to ensure people received safe care. Medicines were managed safely. Risks to people were assessed and staff supported people to ensure risks were managed. There were enough staff and people received support in a timely manner from staff who were not rushed.
There were effective Infection prevention and control systems in place. The home was clean, and staff wore personal protective equipment in line with current guidance.
Effective systems for monitoring and improving the service were in place and ensured the provider and registered manager had an overview of the quality of the service. We received extremely positive feedback about the registered manager and the improvements they had made. The registered manager promoted a positive, caring culture that ensured people were at the heart of all the service did.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 20 November 2020) and there were multiple breaches of regulation. The provider sent monthly reports after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.
We carried out an announced focused inspection of this service on 12 August 2020. Breaches of legal requirements were found. The provider was required to send monthly reports to CQC showing the improvements made.
We undertook this focused inspection to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Edgehill Care on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Edgehill Care Home is a residential care home providing personal and nursing care to 53 people aged 65 and over at the time of the inspection.
Edgehill Care Home can accommodate up to 60 people in one building which is on one floor. The service supports people living with dementia.
People’s experience of using this service and what we found
Care records were not always fully completed. Risks to people were not always assessed and managed. Medicines were not always managed in line with good practice guidance and the provider’s medicine policy.
Whilst some improvements had been made since the last inspection in relation to governance and oversight, systems were still not always effective in identifying and addressing quality concerns.
People were positive about living at Edgehill Care Home and told us they felt safe. They were supported by sufficient staff who were knowledgeable about their needs and had time to spend with them.
There were effective infection prevention and control systems in place to ensure the risk of infection was managed.
Everyone we spoke with was positive about the new home manager and complimentary in how hard the home manager and staff had worked during the COVID-19 pandemic to keep people and staff safe.
Relatives told us they had regular contact with the service throughout the COVID-19 pandemic and they felt confident to raise any concerns.
There was an open culture and staff were complimentary about the improved staff morale that had been achieved with the support of the home manager.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was requires improvement (published 1 January 2020) and there were multiple breaches of regulation. We issued warning notices asking the provider to ensure they met the regulations by a specified date. This service has been rated requires improvement for two consecutive inspections and was rated inadequate at the inspection carried out in March 2019.
Why we inspected
We undertook this focused inspection to check whether the Warning Notice we previously served in relation to Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. This report only covers our findings in relation to the key questions Safe and Well-led which contained the previous breaches.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same as the last inspection, requires improvement. This includes the findings at this inspection.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.
We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to the safe management of medicines and the effectiveness of systems to monitor the quality and safety of the service at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. We will work with the local authority to monitor progress. If we receive any concerning information we may inspect sooner.
Edgehill Care Home is a residential care home providing personal care to 46 older people aged 65 and over and younger adults at the time of the inspection.
Edgehill Care Home accommodates up to 60 people in one adapted building. The service is on one floor.
People’s experience of using this service and what we found
Effective action had not been taken to address all of the previous concerns identified at the last inspection. Systems to monitor the quality of the service were still not effective and had not identified all of the issues found during this inspection. The registered manager did not have a clear overview of the service.
The provider had introduced an electronic care planning system which was in the process of being implemented at the time of the inspection. However, care records on the new system were not always complete and accurate.
Medicines were not always managed safely, and risks to people's safety were not always assessed and managed effectively. People told us they felt safe living at the service. There were sufficient staff to meet people’s needs and there were effective systems in place to support the provider to make safer recruitment decisions.
People enjoyed the food and benefitted from staff who were skilled and knowledgeable about their needs. Staff contacted external professionals when needed and worked with them to support people’s health care needs.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Staff were kind and caring. People were treated with dignity and were supported to have control over their lives. Staff valued people as individuals.
There were a range of activities available and people were involved in deciding the activities they would like arranged. Complaints were investigated and responded to effectively.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was inadequate (published 11 June 2019) and there were multiple breaches of regulation. The provider has been sending monthly reports to CQC showing the improvements they have made. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service was also rated requires improvement at a previous inspection on 8 March 2018.
This service has been in Special Measures since 11 June 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This was a planned inspection based on the previous rating.
Enforcement
We have identified breaches in relation to the management of medicines and systems to keep people safe and systems to monitor the quality of the service at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
People’s experience of using this service:
People’s medicines were not managed safely. Safe systems were not in place to dispose of medicines which were no longer needed. There were gaps in some topical medicines administration records seen.
People told us they were happy with the cleanliness of their rooms. People’s equipment was not always cleaned. We also saw the environment was not always cleaned, this was caused in part by a lack of maintenance to toilets and bathrooms.
People’s risks were not routinely identified or measures put in place to keep people safe. Risks in the environment had also not been identified so that safe systems of work could be put into place.
People were not always supported to make their own decisions and were not involved in planning their care. People had their own care plan which was not always up to date.
People were supported by staff who were not always trained and regularly supported in their roles. Staff understood safeguarding responsibilities and told us they would report any concerns to their manager.
People were not provided with person-centred care and support. Routines were not personalised, there was a lack of activities provided to meet individual needs.
Quality monitoring systems were not robust and had not identified all our concerns. The registered manager did not have effective oversight of the service. They were not aware of all the issues found.
People had provided feedback but the provider had not always taken action to make improvements where needed.
Despite the shortfalls at this service, people told us they felt safe and the staff were kind. Some staff had worked at the service for a long time which people appreciated. People were able to see healthcare professionals when needed.
People had their own rooms which they had personalised. We observed staff knocked on people's doors before going into their rooms promoting privacy.
Mealtimes were relaxed and people told us they enjoyed the food. Snacks and drinks were available around the home.
People could have visitors when they wished. People and their relatives told us they knew how to make a complaint if they needed to. Complaints were documented and had been investigated.
People and their relatives were kept up to date with news from the home in a quarterly newsletter. The service also used social media to record activities and events.
Accidents and incident were reviewed and had been analysed. Action was taken to try to reduce the risk of re-occurrence.
Rating at last inspection: At our last inspection in January 2018 we rated the service as Requires Improvement. We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because medicines were not managed safely.
Why we inspected: This was a planned comprehensive inspection based on the rating at the last inspection.
Follow up: We have found one repeated breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In addition, we have found five further breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following this inspection, we wrote a letter of intent to the provider to seek reassurance on how they would mitigate the immediate concerns and risks to people. The provider sent us a comprehensive response detailing the action they would take to mitigate the immediate concerns. We have asked the provider to send us a monthly action plan using Section 64 of the Health and Social Care Act 2008.
The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep this service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect the service within six months to check for significant improvements.
The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as Inadequate for any of the five key questions it will no longer be in special measures.
At the last inspection in November 2015, the service was rated Good. We carried out a comprehensive inspection on 31 January and 1 February 2018. At this inspection we found the service had deteriorated to Requires Improvement.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People’s medicines were not safely managed. Staff did not always administer medicines safely, in accordance with the provider’s policy or national best practice guidance.
Sufficient numbers of staff were deployed at the time of our visit. Staff performance was monitored. Staff received supervision and training to ensure they could meet people’s needs.
Staff demonstrated a good understanding of safeguarding and whistleblowing and knew how to report concerns.
Risk assessments and risk management plans were in place. We found improvements were needed to ensure all appropriate actions were taken to keep people safe.
Incidents and accidents were recorded and the records showed that actions were taken to minimise the risk of recurrences.
People were supported with food and fluids and provided with choices at mealtimes. Where people were assessed as at risk of malnutrition, they were monitored and actions taken in consultation with external health professionals.
Staff were kind and caring. We found people were being treated with dignity and respect and people’s privacy was maintained.
Activities were provided. Recruitment was taking place for dedicated activity staff posts.
Systems were in place for monitoring quality and safety and actions were taken where areas for improvement and shortfalls had been identified. The audits had not identified the shortfalls we found.
We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we told the provider to take at the back of the full version of this report.
Edgehill Care Home provides accommodation which includes personal care for up to 59 older people. At the time of our visit 58 people were using the service. The home is situated on one level with bedrooms being located in three corridors. There are communal lounges in each corridor with a central communal area, kitchen and laundry. The home is part of Agincare, which is a family run business.
A registered manager was employed by the service to manage the day to day operations of the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People told us they felt safe living at the home. Staff understood their responsibilities and the actions they needed to keep people safe from harm and abuse. Risks to people’s health and safety were identified and plans were in place to minimise these risks.
Staff knew people well and supported them to with maintaining their independence. People and their relatives told us staff treated them or their relative with kindness and respected their privacy and dignity.
People were supported to have sufficient to eat and drink to maintain good health. People told us they enjoyed the food and that there was always plenty available.
People’s medicines were managed safely and they had access to health care services when required.
The registered manager investigated complaints and concerns. People, their relatives and staff were supported and encouraged to share their views on the running of the home. Their views were taken into account in the planning of the service.
Health and social care professionals spoke positively about the care and support people received and praised the management team. They said they found the staff and management team approachable and told us they sought advice and guidance where appropriate regarding people’s changes in care and support.
The provider’s had quality monitoring systems in place. Accidents and incidents were investigated and discussed with staff and at team meetings to minimise the risks of reoccurrence.
Arrangements were in place for keeping the home clean and hygienic and to ensure people were protected from the risk of infections. During our visit we observed that bedrooms, bathrooms and communal areas were clean and tidy and free from odours.
Staff acted in accordance with the requirements of the Mental Capacity Act 2005. Where people did not have the capacity to make the decisions themselves, mental capacity assessments were in place and records showed that decisions had been made in line with best interests. Where required Deprivation of Liberty Safeguarding applications had been submitted by the registered manager.
People had positive views of Edgehill. Examples of comments from people who used the service included, the staff 'are brilliant' and that they 'do their best' and their care was 'really good', a relative said that Edgehill 'looked after Mum really well'.
People were effectively assisted by the staff so that their range of care needs were met.
The majority of people spoken with felt satisfied with the meals that were provided at the home.
People were assisted by staff who were suitably trained and supervised, to ensure good care practice. People received appropriate care and support, to meet their needs. Staff were able to obtain further qualifications and were trained in subjects relevant to peoples' needs.
The quality of care and overall service people received was checked and monitored to make sure it was safe and suitable.
You can see our judgements on the front page of this report.
We observed care practices and saw that people were receiving effective, safe and appropriate care.
People felt safe within the home and staff were aware of their responsibilities to recognise and report a suspicion or allegation of abuse.
Staff we spoke with told us that there were enough staff to ensure people were given an excellent standard of care. One member of staff told us that 'I love my job and feel I can make a real difference to people's lives.'
The manager took account of comments from people to help improve the service.
We were told that continence care was managed professionally and sensitively by the staff team.
The home had increased the number of people it accommodated and had made changes to the way staffing was organised. It was also changing the sytems and recording used for assessing, planning and reviewing care and support. Staff told us these changes were positive improvements.
We were told that sometimes during the ealry hours of the morning the night shift could become very busy and that the staffing occiasionally needed to be reviewed for this time period.
One person said the staff were 'second to none' and they had no problems. They added that staff showed them concern and the personal assistance was 'wonderful'. They reiterated that they were 'exceptional staff'.
People confirmed with us that they had signed agreements to the care they received.
We spoke with the relative of a person admitted into one of the 'crisis' spaces. They said that they and the person living in the home, felt that the care was very good, the food was good. Another relative was happy with what they had seen.
We found that the home was clean and tidy. People were engaged in doing various things like watching television and reading. We saw staff were going about their work in a calm and professional way.