Eden Lodge Residential Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People’s needs were not adequately assessed, documented or reviewed to ensure that people received care and support in line with their needs. Care plans contained incorrect or unclear guidance on how people should be supported. This meant staff could not always rely on care plans as an accurate source of guidance to support people consistently, this placed people at risk of harm.

The provider did not always ensure when reviews of people’s care were undertaken this was done in consultation with people and/or their representatives where appropriate. Records showed monthly reviews were undertaken but this was completed by staff and did not always indicate people had been involved. People living at the service could not recall being involved in any reviews for their care plans.

This placed people at risk of not being supported in line with their assessed needs.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

People did not receive support based on current good practice or legislation. We found a task focused, institutionalised approach amongst the staff team, which was not in line with current best practice for supporting older people and people living with dementia or mental health needs.

We found care plans had not included external healthcare professionals’ direction. This placed people at risk of harm and poorly managed health conditions.

People were at risk of choking, for example, one person was prescribed thickener to be added to their drinks, however there was no evidence this has happened. This resulted in a lack of actions being taken to improve people’s nutritional intake.

There was a lack of oversight in relation to the monitoring of people’s skin integrity, to prevent skin damage. For example, records did not demonstrate people received pressure relief at required intervals. The provider failed to carry out checks or monitor records which placed people at risk of harm.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

The provider failed to ensure effective leadership within the home. The manager had recently left, the provider did not ensure sufficient oversight of the service. Checks to confirm that the home was being safely managed and maintained had not taken place which placed people at risk of harm.

Healthcare professionals regularly visited people requiring care. However, people’s needs were not comprehensively assessed and documented therefore the provider was not able to share an accurate assessment with other services.

Staff verbalised that they knew people’s needs, however they were unable to explain the content of people’s care plans. We could not be assured staff had up to date knowledge of people’s care plans, meaning people were at risk of receiving the incorrect care and support.

Systems were in place to support staff communication between shifts. Staff told us a handover was completed before staff started their shifts. Handovers, included discussions of key information about people’s needs, which included concerns staff had about people.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

There was restrictive practices found during this assessment. This meant people were not supported to be independent, nor did they have choice around their day.

Records were not always available to support people who had access to and received regular routine health checks, such as dentist, opticians and chiropodist. People were not registered with dentists, and the provider did not have details of when people last had a check-up, or when this would be due. Where people had declined oral hygiene, it had been documented but not escalated.

We asked the provider to take action which they said they would do straight away.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive andconsistent, or that they met both clinical expectations and the expectations of people themselves.

We found ineffective record keeping, therefore we were not assured the provider had effective monitoring systems in place of people’s care and treatment. Staff used an electronic care planning and recording system to record interactions as part of the daily records. On reviewing these records, we found people had not been supported with repositioning regularly, which placed them at risk of harm from skin damage. We also found some entries appeared to be copied into more than one day. This meant that notes were not contemporaneous, and we could not be assured it was a true reflection of the interactions between staff and people living at the service.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The provider did not consistently work within the principles of the Mental Capacity Act (2005) (MCA).

Where people were deemed to lack capacity, some mental capacity assessments had been completed; however, these did not relate to all relevant decisions requiring assessment. The assessments in place had not been reviewed for several years. The home operated CCTV in communal areas; however, consent had not been recorded for people who used the service. Where people lacked the mental capacity to consent, the provider had not completed decision-specific mental capacity assessments or best-interest decision-making records in relation to the use of CCTV.

This meant decisions may not have been made in accordance with the Mental Capacity Act 2005, and there was no assurance that people's rights, preferences and best interests had been consistently considered.