Archived: Edenmore

Updated 3 July 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Prior to the inspection we reviewed a range of information to ensure we were addressing potential areas of concern and to identify good practice. This included the Provider Information Record (PIR), which asks the provider to give some key information about the service, including what the service does well and improvements they plan to make. We also reviewed previous inspection reports and other information held by CQC, such as notifications. A notification is information about important events which the service is required to tell us about by law.

This inspection took place on 3 and 5 March 2015 and was unannounced. On the first day the inspection team included two inspectors, a pharmacist inspector and an expert by experience. An expert-by-experience is a person who has personal experience of caring for someone who uses this type of care service. During the first day we spent time observing how care and support was being delivered and talking with people, their relatives and staff. This included 14 people using the service, nine relatives and friends or other visitors, and 16 staff. This included care staff, nurses, domestic staff, registered provider, senior managers, and the administrator.

On the second day, one inspector spent time looking in more detail at records relating to people’s care as well as audits and records in relation to staff training and recruitment. We looked at six care plans and daily records relating to the care and support people received. Care plans are a tool used to inform and direct staff about people's health and social care needs.

We also used pathway tracking, which meant we met with people and then looked at their care records. We looked at four recruitment files, medication administration records, staff rotas and menu plans. We also looked at audit records relating to how the service maintained equipment and building. Following the inspection we spoke with two healthcare professionals who know the service.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Updated 3 July 2015

This inspection took place on the 3 and 5 March 2015 and was unannounced.

Edenmore is registered to provide nursing and personal care for up to 48 people. At the time of the inspection there were 38 people living at the service. Most people were living with dementia and health conditions related to older age.

The service has a registered manager who has been in post for over ten years. 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.

Not all care staff had a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty safeguards. Staff were assisting people to make choices in their everyday lives but where people lacked capacity, staff did not always understand the law which underpinned those people’s rights.

Some wheelchairs and parts of the kitchen were in need of cleaning, although most other parts of the home were kept clean and fresh smelling. There were some arm chairs which were dirty and one had a hole in the arm rest which would have made it difficult to keep clean and free from cross infection. When highlighted this armchair was removed and the kitchen and wheel chairs were cleaned.

Systems were in place to ensure people were protected from the risk of cross infection. Although there were  individual risk assessments or care plans in place for people who had been ill recently with sickness and diarrhoea, we were told these had been archived.

Care and support was being well planned and staff had a good understanding of how to support people. However some records relating to some individual’s had not been updated to reflect their changing needs. The service was in the process of introducing having a named nurse for each person, who would have responsibility to ensure the care plans and risk assessments were kept up to date. They were confident this would ensure all plans were updated in a more timely way.

The staff team were well established, trained and supported to meet people’s needs. They had a good understanding of people’s wishes and preferred routines and planned their care and support in line with people’s needs and wishes. There were sufficient numbers of staff on duty across all shifts to meet people’s needs in a timely way. The nursing and care staff were supported by cooks housekeeping, administrator and maintenance personnel. People and their relatives spoke highly about the caring attitude and skills of the staff at Edenmore. One person said ‘‘This place is brilliant. Nothing is too much trouble. I feel cared about here. Everyone puts themselves out to be helpful and kind.’’

The service had a robust recruitment process to ensure only staff who were suitable to work with vulnerable people were employed. New staff received an induction to help them understand their role, but this had not always been fully documented.

Medicines were safely stored and administered by competent staff, but records were not always clear when a variable dose of medicines had been prescribed.

People were supported to eat and drink and where risks of poor nutrition had been identified, this was closely monitored. People’s health care needs were being met and monitored.

Staff reported that they felt well supported and had confidence in the registered manager. Staff felt their concerns, ideas and suggestions were listened to and acted upon. There was an ethos of caring and supporting people and the staff team. Staff described the service as a caring environment and a ‘‘good place to work.’’ There was a planned training programme covering all aspects of health and safety and some more specialised areas such as working with people with dementia care needs and care of the dying. Staff had regular opportunities to discuss their work and receive support and supervision, although this was not always recorded.

Systems were in place to ensure people and their family had opportunities to have their views heard both formally and informally. Relatives reported they were made to feel welcome and had opportunities to talk to staff and registered manager about any concerns or ideas they had in relation to any aspect of the running of the service.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of this report.