Edgecumbe Lodge Care Home

Updated 6 February 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

This was a targeted inspection in response to health and safety concerns received about the service from the local authority but became a focused inspection due to additional concerns identified at the service.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of two inspectors and an operations manager.

Service and service type

Edgecumbe Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Edgecumbe Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who lived at the service and 2 visitors. We also spoke with the registered manager, the deputy manager, the nominated individual, the provider’s HR compliance manager and 4 care staff at the service. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a sample of people's care and support records. We also looked at records relating to staff recruitment and the management of the service such as incident and accident records, staffing rotas, meeting minutes, training records and audits.

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

Updated 6 February 2024

About the service

Edgecumbe Lodge care home is a residential care home providing the regulated activity of accommodation with personal care for up to a maximum of 21 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 15 people using the service.

Edgecumbe Lodge care home is a large, detached property in a residential area. The building has four floors with bathrooms on each floor. There is a lift and stairlift for accessibility.

People’s experience of using this service and what we found

This was a targeted inspection that considered the aspects of health and safety within the service in response to concerns received from the local authority. We found that some areas of health and safety had been rectified such as broken tiles in the porch had been fixed but there were a number of risks that had not been addressed. Some aspects of the premises and equipment were not clean or properly maintained which created a hazard around infection control.

The provider and registered manager’s oversight of environmental risk was poor. We identified shortfalls in this inspection that had not been identified by the provider. Fire safety was not always maintained in the home. Some fire doors on the ground floor of the home did not close properly. The Fire evacuation folder was not kept up to date. An electrical installation conditions report dated 08 August 2019 had identified a number of urgent remedial work that was required at the service, this had not been carried out in a timely way.

The provider’s internal governance processes did not highlight the concerns we found at this inspection. Quality assurance and monitoring was carried out but was not effective. However, further work and more regular audits were required both at manager and provider level, so that the service improved for people living in the home.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 04 April 2023). The service remains rated requires improvement. This service has been rated requires improvement for the last 3 consecutive inspections.

At this inspection we found the provider remained in breach of regulations.

Why we inspected

We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about health and safety. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with environmental risks, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

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 COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, and well led sections of this full report.

Enforcement

We found several breaches of regulation and issued the provider with warning notices in relation to premises and equipment and good governance.

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 continue to monitor information we receive about the service, which will help inform when we next inspect.