22 June 2023
During an inspection looking at part of the service
Edgecumbe Lodge care home is a residential care home providing the regulated activity of accommodation with personal care for up to a maximum of 21 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 15 people using the service.
Edgecumbe Lodge care home is a large, detached property in a residential area. The building has four floors with bathrooms on each floor. There is a lift and stairlift for accessibility.
People’s experience of using this service and what we found
This was a targeted inspection that considered the aspects of health and safety within the service in response to concerns received from the local authority. We found that some areas of health and safety had been rectified such as broken tiles in the porch had been fixed but there were a number of risks that had not been addressed. Some aspects of the premises and equipment were not clean or properly maintained which created a hazard around infection control.
The provider and registered manager’s oversight of environmental risk was poor. We identified shortfalls in this inspection that had not been identified by the provider. Fire safety was not always maintained in the home. Some fire doors on the ground floor of the home did not close properly. The Fire evacuation folder was not kept up to date. An electrical installation conditions report dated 08 August 2019 had identified a number of urgent remedial work that was required at the service, this had not been carried out in a timely way.
The provider’s internal governance processes did not highlight the concerns we found at this inspection. Quality assurance and monitoring was carried out but was not effective. However, further work and more regular audits were required both at manager and provider level, so that the service improved for people living in the home.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 04 April 2023). The service remains rated requires improvement. This service has been rated requires improvement for the last 3 consecutive inspections.
At this inspection we found the provider remained in breach of regulations.
Why we inspected
We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about health and safety. A decision was made for us to inspect and examine those risks.
We inspected and found there was a concern with environmental risks, so we widened the scope of the inspection to become a focused inspection which included the key questions of 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 COVID-19 and other infection outbreaks effectively.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, and well led sections of this full report.
Enforcement
We found several breaches of regulation and issued the provider with warning notices in relation to premises and equipment and good governance.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.