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Edwina Mountbatten House Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 14 April 2021

About the service

Edwina Mountbatten House is a residential care home providing personal care to 16 people aged 65 and over at the time of the inspection. The care home can support up to 17 people, some of whom may have dementia. People are accommodated in one building, which is arranged over two floors and surrounds a courtyard. The registered provider is The Countess Mountbatten of Burma Memorial Trust, a registered charity run by a board of Trustees.

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

There were areas where infection control practice needed to be improved to reduce the risk of infection and keep people safe.

Improvements were needed to ensure that the premises were fully secure and did not present risks to people. The provider has taken the required action to address these since the inspection.

Medicines were well managed overall, and people received their medicines as prescribed. We found some areas where medicine practice could be improved.

We were assured that there were enough staff to meet people’s needs. Staff had been recruited safely.

People’s relatives told us they felt confident that their family members were safe.

Staff knew residents well and provided support in an attentive and kind way.

We were not assured that systems in place to monitor the service, reduce risks to people and drive improvement were fully effective.

Records relating to people’s care were not always accurate or up to date. This had not been identified by quality assurance systems.

We saw that the provider had invested in refurbishment to improve the décor of the building.

People and their relatives were able to give feedback about their care and this was acted upon.

People’s relatives felt the service had kept them informed throughout the COVID-19 pandemic and spoke positively about the leadership team.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was requires improvement (published 30 April 2019). That inspection identified a continued breach of the Regulations regarding good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found that although some improvements had been made, the provider was still in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections. We will describe what we will do about the repeat requires improvement in the follow up section below.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 25 March 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance.

We undertook this focused, short notice inspection on 29 January 2021 to check that the provider had followed their action plan and to confirm they now met legal requirements. The inspection was also based on the previous rating. This report only covers our findings in relation to the Key Questions 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 coronavirus and other infection outbreaks effectively.

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 requires improvement. This is based on the findings at this inspection. Please see the Safe and Well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all repo

Inspection areas


Requires improvement

Updated 14 April 2021

The service was not always safe.

Details are in our safe findings below.



Updated 14 April 2021



Updated 14 April 2021



Updated 14 April 2021


Requires improvement

Updated 14 April 2021

The service was not always well-led.

Details are in our well-Led findings below.