Archived: Edenbridge Manor Care Home

Updated 29 June 2022

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.

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 was carried out by two inspectors and an Expert by Experience.

An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Edenbridge Manor Care Home 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. Edenbridge Care Home 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post. However, there was a manager in post who was going through the process to become registered with CQC.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We reviewed all of the information we held about the service. This included statutory notifications received from them and safeguarding concerns.

We used all this information to plan our inspection.

During the inspection

On the day of inspection, we spoke with 12 people and one relative about their experience of the care provided by the staff at Edenbridge Manor. We also spoke with seven staff, including the manager and the provider’s senior management team.

We reviewed a range of documentation, including seven people’s care plan, medication processes and records and four staff recruitment files. We also looked at the governance systems within the service which included audits, accidents and incidents, policies and procedures.

Following the inspection

We received feedback from eight relatives with their views on the care their loved one was receiving. We also received further documentation from the manager which included information on training, supervision and the opportunities for people and staff to be involved in the service.

Updated 29 June 2022

About the service

Edenbridge Manor Care Home is a purpose-built residential care home providing accommodation and personal care for up to a maximum of 85 people. The service provides support to people who have various health issues or are living with dementia. At the time of our inspection there were 45 people using the service.

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

Although people and their relatives told us Edenbridge Manor was a safe place, we found some staff did not always recognise or report safeguarding incidents to the local authority for review. Risks to people, although recognised, were not always addressed by staff meaning people may experience potential avoidable falls.

Deployment of staff across the service was inconsistent which meant that some people did not always receive the support they needed to help ensure they were safe.

People lived in an environment that was clean and hygienic and people’s rooms were personalised. However, further work was needed to ensure those living on the first floor of the service were supported with their dementia needs through adaptation and signage.

The quality of the service was reviewed through a series of audits and governance processes and as such some of the shortfalls we had identified at our inspection had already been recognised by management. However, not all of the gaps in people's care had been picked up through the governance arrangements within the service.

People received care from staff who were appropriately trained and demonstrated a caring, respectful and responsive approach. Staff knew people as individuals and provided person-centred care.

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.

People received the medicines they were prescribed and were supported to access health care professional input when needed. People were provided with sufficient food and drink to help ensure they remained healthy, and they were given the opportunity to make their own decisions in relation to their care.

People were provided with a range of activities and the manager had recruited an additional staff member to help ensure those people living with dementia had appropriate activities provided for them. People’s individual communication needs were recognised and responded to appropriately.

Everyone spoke highly of the manager and the service provided to them and staff felt supported and valued. The manager applied duty of candour when necessary and investigated and responded to complaints.

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

Rating at last inspection

This service was registered with us on 12 February 2021 and this is the first inspection.

Why we inspected

This visit was the first inspection of this newly registered service.

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.

The overall rating for the service is Requires Improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the key questions of Safe, Effective and Well-led.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

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 monitor the service and will take further action if needed.

We have identified breaches in relation to potential incidents of abuse, risks to people and staffing levels. We have also issued recommendations to the registered provider in relation to the environment for people living with dementia and the induction process for agency staff.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will continue to monitor information we receive about the service, which will help inform when we next inspect.