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Edensor Care Centre (Diagrama Healthcare) Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 17 January 2019

At the last inspection on 27 and 29 March 2017, the service was rated as requires improvement. This comprehensive unannounced inspection was carried out on 26 November 2018. At this inspection, whilst we found that the service had made improvements in activities for people living at the service, improvements continued to be needed in a number of key areas as described below. This is the second time the service has been rated as requires improvement.

The service is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection.

Edensor is registered to support 48 older people, some of whom may be living with dementia. On the date of our inspection, 41 people were being supported by the service.

At the time of inspection there had not been a registered manager at the service for three months. The deputy manager, who had worked at the service for some years had been employed into the manager role and was in the process of submitting an application for registration.

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.

People who were able to speak to us, told us that they were happy living at the service and that they felt supported and cared for by staff. Relatives told us they felt their loved ones were cared for safely.

Staff had received training on safeguarding adults from abuse and understood their responsibilities to prevent people from experiencing harm.

Risks were not always explored in a robust way. Where risk information was gathered, it was not used in a way to inform staff how to best manage and mitigate the risks to people.

The clinical nurse lead and qualified nursing staff managed medicines and medicine audits. However, these audits did not identify concerns we found on the day of inspection. This was mirrored in some safety audits. Whilst safety audits had taken place within correct timescales, checks carried out during this inspection demonstrated that they were not always accurate.

Staff were recruited robustly and safely and extra care had been taken to ensure that those people interviewed could demonstrate the values of the organisation.

The new training coordinator worked with a clear and concise training plan to ensure that staff were up to date with mandatory training. They also had been trained to carry out face to face training in a variety of key areas.

People had access to a variety of choices of food and fluid which were available throughout the day, and were also able to request meals that were not on the menu. Improvements had been made with the meal times and choice. However, this was an area that could continue to be improved, including the meal time experience and the recording of people’s specific nutritional and fluid needs.

We made a recommendation about the meal time experience for people living with dementia.

The provider had made significant improvements in the quality and layout of the service and was in the process of continuing to improve this area. There continued to be issues with cleanliness.

The staff were caring. They knew people well and were sensitive to their needs. People were encouraged to be as independent as possible and staff treated them with dignity and courtesy.

The manager and activity coordinator had worked tirelessly to improve the quality of activities provided to people and demonstrated continuous drive to ensure that all people living at the service had access to various opportunities and experiences. This included some innovative and creative thinking about how to engage external org

Inspection areas


Requires improvement

Updated 17 January 2019

The service was not always safe

Medicines were stored safely but records of administration for topical creams were poor.

Some peoples identified risks were being monitored but this information was not used to mitigate and manage risk effectivity.

Infection control and cleanliness at the service needed to improve.

Staff at a good understanding of safeguarding procedures and how to report concerns.

There was sufficient staff available to meet people’s needs.



Updated 17 January 2019

The service was effective

Staff had sufficient induction and training to support people safely. The provider had provided additional learning opportunities for staff.

People had access to external health professionals when additional needs were identified.

Improvements had been made to the dining experience, although we have made recommendations to improve this area further.

Staff had a good understanding of the mental capacity act and capacity was considered through care provided.



Updated 17 January 2019

The service was caring

People told us that staff were caring and kind.

Staff involved people and their loved ones in various experiences and opportunities at the service.

People, relatives and staff were encouraged and supported to voice their views about the service

Some staff went above expectations to support additional activities outside of their working hours.



Updated 17 January 2019

The service was responsive

The manager had identified that care plans needed to be more streamlined and collaborative and were working towards computerised records. However, people were receiving care in line with their personal needs.

Activity staff and had worked hard to ensure that people had access to a range of activities, both within the service and local community.

There was a robust complaints system in place and where complaints had been made, the manager had dealt with these appropriately.


Requires improvement

Updated 17 January 2019

The service was not always well led.

The service had been without a registered manager for six months and we have not received an application by a person intending to be registered as the manager.

Shift co-ordinators did not always lead in a manner that encouraged care staff to engage with people in a variety of positive engagements.

The manager did not have a clear oversight of the governance processes in place, and consequently had not identified the concerns that we found on inspection.