You are here

Edwina Mountbatten House Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 30 April 2019

About the service: Edwina Mountbatten House is a care home. It does not provide nursing care. It can accommodate up to 16 people. At the time of the inspection there were 13 people using the service. The registered provider, The Countess Mountbatten of Burma Memorial Trust, is a registered charity run by a board of Trustees.

Rating at last inspection: At the last inspection in February 2018, we rated the service as ‘Requires improvement’. That inspection identified two breaches of the Regulations. There had been a failure to ensure that there were strong governance systems in place and records relating to people’s care were not always complete. The provider had also failed to ensure that new staff received appropriate training.

We also made four recommendations. These were:

- That a systematic approach be used to determining the numbers of staff deployed.

- That a more robust pre-admission assessment form be developed.

- That action was taken to ensure that infection prevention and control policies and procedures reflected statutory guidance.

- That staff be provided with training to equip them with the skills they needed to develop end of life care planning with people and their relatives.

People’s experience of using this service:

This inspection found some improvements had been made but many of these were yet to be fully embedded.

The systems in place were not yet being fully effective at identifying compliance with the Regulations and delivering all the improvements needed to achieve a rating of ‘Good’.

People had always received their medicines as prescribed and staff were not always following best practice frameworks in relation to the management of medicines.

Some of the risks associated with people’s care had not been consistently assessed and planned for. Whilst accidents and incidents were documented and investigated. It was not always clear that sufficient action had been taken to reduce similar incidents from happening again.

Whilst planned staffing levels had not always been achieved, people and staff did not feel this had impacted upon the provision of safe care.

Systems and processes were in place to safeguard people from the risk of abuse.

The home was visibly clean and staff followed appropriate infection control measures.

Improvements continued to be embedded to ensure that staff, new to care, consistently received a comprehensive induction mapped to the Care Certificate standards. Staff received regular training opportunities to keep their knowledge up to date.

The registered manager had started to implement an effective and robust supervision programme.

There was a clear focus on the importance of seeking peoples consent, and there was evidence that people were always offered choice and control over the care they received.

Overall assessments of people’s needs were suitably detailed and holistic. Staff were using evidence based guidance to enhance the care provided and to achieve positive outcomes for people.

Where necessary a range of healthcare professionals including GP’s and district nurses had been involved in supporting people to maintain good health.

People told us the environment was homely and comfortable and they were positive about their rooms which they had been able to personalise according to their individual tastes. However, we found that the environment was still not consistently decorated and equipped to a good standard throughout. This had been a concern at out last inspection.

The provider remained committed to the programme of refurbishment which it was hoped would now start in the Autumn. We have made a recommendation about consulting best practice guidance on how to effectively design environments for people living with dementia including the use of appropriate technology, signage and decorating styles.

People continued to be treated with kindness, respect and dignity. Staff understood the importance of supporting people to maintain their independen

Inspection areas


Requires improvement

Updated 30 April 2019

The service was not always safe

Details are in our Safe findings below.



Updated 30 April 2019

The service was effective

Details are in our Effective findings below.



Updated 30 April 2019

The service was caring

Details are in our Caring findings below.



Updated 30 April 2019

The service was responsive

Details are in our Responsive findings below.


Requires improvement

Updated 30 April 2019

The service was not always well led

Details are in our Well led findings below.