Edenmore Nursing Home

We found the following examples of good practice:

There were clear plans and policies about how the wing would be used to keep people safe.

The separate entrance would enable staff to arrive at work, follow donning and doffing procedures and enter the wing, via a key code, without needing to access the main premises. A separate staff team had been sourced who would only work in the wing, including domestic staff. An area had been made to accommodate staff breaks adhering to social distancing.

All five rooms were clean and had separate laundry, waste and clinical waste bins. Equipment such as mobility aids, would be provided separately depending on each person’s needs and included on the domestic cleaning schedule. The lift would be cleaned after every use. The wing was able to be well ventilated.

Each room had been equipped for a comfortable stay and would also include televisions. Each person would have a family and friends contact form and be supported to use technology and phones to maintain regular contact with them. Additional wifi receivers had been sourced. There would be a brochure explaining visiting guidelines.

There were regular people and staff testing programmes in place. Contingency and admission plans were clear and included easy access to the wing by people arriving in an ambulance.

Safe procedures were known by staff to minimise the risk of transmitting Covid-19. Staff had received training on donning and doffing and on the coronavirus pandemic from various sources including local health and social care professionals, e-learning and from in-house training sessions. There were good stocks of all personal protective equipment (PPE). There were supplies of PPE available around the wing.

People’s experience of using this service:

People were not all able to fully verbalise their views therefore they were not able to tell us verbally about their experience of living there. Therefore, we observed the interactions between people and the staff supporting them. Staff engaged with people with kindness and compassion and shared warm interactions.

People lived in a service that kept them safe. Staff had been recruited safely and had received training on how to recognise and report abuse. People were supported to take their medicines safely. Audits and checks were carried out, so any problem could be identified and rectified.

Staff promoted people’s dignity and privacy. Staff understood their responsibilities to protect people from abuse and discrimination. They knew to report any concerns and ensure action was taken.

People were supported to lead a healthy lifestyle and have access to healthcare services. Staff recognised any deterioration in people's health, sought professional advice appropriately and followed it.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The provider recognised the importance of social activities. People were encouraged to engage in meaningful activity to aid both their physical and emotional well-being.

People knew how to make a complaint if necessary. They said if they had a concern or complaint they would feel happy to raise it with the management team.

The manager and staff were very committed to ensuring people experienced end of life care in an individualised and dignified way.

A system of audits and monitoring carried out by the provider helped ensure any gaps in practice or required improvements were identified. Audits were used to continually review and improve the service.

Rating at last inspection: Good (report was published January 2017)

Why we inspected: This was a scheduled comprehensive inspection.

Follow up: We will continue to monitor the service to ensure that people continue to receive safe, compassionate, high quality care.

The service met the characteristics for a rating of "good" in all the key questions we inspected. Therefore, our overall rating for the service after this inspection was "good". For more details, please see the full report which is on the CQC website at www.cqc.org.uk

We had carried out an unannounced comprehensive inspection of this service in September 2016. This was the first inspection for this service, which was registered on 1 February 2016 as a new provider of the service. We rated the service as ‘good’ and found they were meeting all of the regulations. We undertook a focused inspection in December 2016 because of concerns we had received. At that inspection we rated the ‘Safe’ domain as requires improvement because we found a breach of regulations. This was because we found the provider was not doing all that was reasonably practical to mitigate risks to people. This meant people were not always protected from risks posed by another person using the service. We undertook this focused inspection to check that they had followed their action plan and to confirm that they now met legal requirements. At this inspection we found improvements had been made. Measures had been taken to protect people and risks were being managed.

This report only covers our findings in relation to the ‘safe’ domain.

Edenmore is a nursing home registered to provide care and treatment for a maximum of 47 people. Most are living with the condition of dementia. At the time of our visit 42 people were staying at the home.

The 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. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Edenmore had a registered manager. The registered manager said they were planning to step down from their role and was working with a new manager to take on the manager’s role.

People said they felt safe at the home. People were protected because risks for each person were identified and managed. Risk assessments were completed and action taken where staff had identified concerns.

At the time of our visit the kitchen was undergoing a major refit. The registered manager had completed a risk assessment to ensure people remained safe during this disruption. Emergency systems were in place to protect people.

There were sufficient staff on duty during our visit to keep people safe. Staff had time to meet people’s needs with many positive caring interactions seen between staff and people. When people became distressed or agitated, staff responded promptly and dealt with this in a calm, skilled and respectful way.

The provider had a robust oversight system to ensure all checks had been completed before a new member of staff started at the service. The provider undertook relevant professional registration checks.

People were protected by staff that were very knowledgeable about the signs of abuse and had a good understanding of how to keep people safe. They had received training in safeguarding vulnerable adults and had regular updates.

People received their medicines safely and on time. Medicines were managed, stored, given to people as prescribed and disposed of safely. The registered manager had identified improvements were needed in relation to the administration of topical creams and were putting these in place.

Accidents and incidents were reported in accordance with the organisation’s policies and procedures.

The environment was safe and secure. There were arrangements in place to maintain the premises and equipment.

Communal areas and people’s rooms were clean with no unpleasant odours. Staff had access to personal protective equipment (PPE’s) such as gloves and aprons.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Edenmore Nursing Home on our website at www.cqc.org.uk.

After that inspection we received concerns relating to people not having their risks safely managed, staff using restrictive practices and people not receiving adequate food. This report only covers our findings in relation to these concerns. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Edenmore Nursing Home on our website at www.cqc.org.uk. We completed this unannounced focussed inspection on 20 December 2016. An inspection manager and inspector completed the inspection. The local authority safeguarding team were also looking into concerns raised and were arranging to discuss these with the registered manager after our visit.

Edenmore is a nursing home registered to provide care and treatment for a maximum of 47 people. Most are living with the condition of dementia. At the time of our visit 41 people were staying at the home.

The 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. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Edenmore had a registered manager. The registered manager said they were planning to step down from their role and was in the process of training a new manager to take on the manager’s role.

During this inspection we found people were not always protected from risks posed by another person using the service. Actions had been taken for the individual to support and monitor them. These included staff monitoring the whereabouts of the person at all times. However during our visit staff were not always aware of where the person was. Where this person was entering people’s rooms, no consideration had been considered regarding putting in measures to protect these people.

People were protected from the risk of malnutrition. Risk assessment were undertaken and people were weighed regularly and actions taken when concerns were identified. There was adequate food and drink available for people.

Accident and incident forms were completed promptly by staff. An analysis of accidents at the home was completed by the registered manager each month to look at patterns and trends. There had been a high level of falls in November 2016. The registered manager demonstrated they had taken action to reduce and prevent further accidents occurring by putting in place further measures.

People’s freedom was protected and restraint practices not used. People were protected by staff who were knowledgeable about the signs of abuse and knew how to report their concerns appropriately. Staff said they were happy they could raise concerns with the registered manager and new manager and that action would be taken.

We will meet with the provider in the New Year to discuss the findings and their action plan. We will then carry out a focused inspection in the near future to check that the regulation is being met.

We identified one breach of regulation at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

Edenmore is a nursing home registered to provide care and treatment for a maximum of 47 people. Most are living with the condition of dementia.

The 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. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Edenmore had a registered manager.

Edenmore was a home where staff said they enjoyed working, people’s family members said they enjoyed visiting and people smiled when they engaged with staff. There was an ethos of care and kindness. Some people had behaviours which were a challenge to the service and distressing to themselves, but the staff understood their needs, were kind, caring and supportive. Staff were patient and had the time to spend with people.

Health care professionals spoke highly of the service people received.

Staff knowledge protected people from abuse and harm; risks were understood and well managed with as little restriction as possible to promote people’s well-being. People received their medicines as prescribed.

People were protected by a well organised and managed recruitment process. Staff practice was monitored through observation and supervision. Staff received a detailed induction and regular training, which they said was very good.

The Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions, and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. People’s consent was sought. Where they were unable to provide informed consent the principles of the MCA and DoLS were followed, so people’s legal rights were upheld.

People received a nutritious diet; the menu was varied and food and drinks were available at any time. Dietary concerns were identified and followed up.

People’s needs were assessed. Their care was planned and kept under regular review. Staff were very responsive to people’s needs, which they understood and were adept at meeting.

People’s views were sought and staff worked hard to engage with people, such as choosing colour schemes for their rooms. People had activities available to them and staff worked to provide a stimulating environment for them.

The registered manager led by example and was well known by people and their family members.

There was an open and progressive culture, where the quality of service and safety was under regular review by the registered manager and the organisation.