Archived: Edenvale Nursing Home

Updated 8 August 2019

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.

This inspection was carried out by two inspectors, a medicines inspector and an expert by experience who had personal experience of using or caring for someone who uses services that support people with dementia.

Service and service type:

Edenvale Nursing Home is a care home. People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Notice of inspection:

The inspection was unannounced. Inspection site visit activity started on 25 October 2018 and ended on 25 October 2018.

What we did:

Prior to the inspection we reviewed any notifications we had received from the service and information we had received from external agencies including the local authority and clinical commissioning group (CCG).

This inspection included speaking to seven people, 11 relatives or visitors, five staff, the registered manager and provider. We also reviewed records related to the care of 12 people. We looked at records of accidents and incidents, audits and quality assurance reports, complaints, four staff files and the staff duty rota for the previous month. We also looked at documentation related to the safety and suitability of the service. We spent time observing interactions between staff and people within the communal areas of the home.

After the inspection we requested further information from the registered manager and provider. Not all of the information was received for example, we requested policies and procedures from the provider and registered manager on two occasions but were unable to review these as they were not received at the time of writing the report. We requested an action plan from the provider and registered manager to see what action would be taken to improve the service. The report includes evidence and information gathered by the other inspector, medicines inspector; Expert by Experience; and from communication with the local authority and CCG.

Updated 8 August 2019

What life is like for people using this service:

• The quality of care people received had significantly deteriorated since the last inspection.

• People had been placed at risk of avoidable harm. Medicines were poorly managed, placing people at risk.

• The culture in the service was poor. Staff were task orientated and supported by a management team who lacked clear oversight and knowledge of what was happening in the service.

• Some people had experienced harm because of poor practice and ineffective governance systems and processes.

• The service met the characteristics of inadequate in all areas we inspected.

• Please see more information in Detailed Findings below.

Rating at last inspection: The service was last rated Good, published on 17 May 2018.

About the service:

Edenvale Nursing Home is a care home that was providing personal and nursing care to 28 people at the time of the inspection. It is registered to provide a service to older people who may be living with dementia, physical disability and mental health needs.

Why we inspected:

This inspection was brought forward in response to incidents that had occurred in the service and concerns that had been raised about the safety and management of the service. At the time of the inspection we were aware of incidents being investigated by third parties.

Follow up:

Following the inspection we referred our concerns to the local authority responsible for safeguarding. In addition, we requested an action plan and evidence of improvements made in the service. This was requested to help us decide what regulatory action we should take to ensure the safety of the service improves.

The overall rating for this registered provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, 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. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from

operating this service. This will lead to cancelling their registration or to varying the terms of their

registration.

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. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.