Edgecumbe Lodge Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst the provider demonstrated aspects of a positive safety culture, incidents and lessons learnt were not always well documented to record actions, identify learning, and embed good practice. We identified several incident records which had not been reviewed and signed off by the manager in a timely way. Although immediate actions had been taken to manage risk, they were not always well documented. Staff told us incidents and lessons learnt were discussed at meetings, however learning was not well documented. We found audits of incident records were not sufficiently robust to identify trends, patterns or opportunities for learning. Despite the shortfalls identified, staff reported and documented incidents and understood their responsibilities to record events and monitor people to ensure their safety. People, relatives and staff told us they felt able to raise concerns with the management team. A person said, “I have not had to raise things, staff are helpful. I could talk to the manager.” We reviewed records of complaints which had been sufficiently documented and responded to appropriately. A relative said, “Complaints, I could raise anytime with anyone but normally they just sort stuff out.” We raised our concerns with the management team and during the assessment the provider took action to improve their monitoring and oversight of incidents.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The provider worked with people to plan and organise their care and support, ensuring continuity. Before moving into the service, people were assessed to make sure their needs could be met. This process included initial assessments, meetings, and a visit to the service. The provider had procedures to support staff with new referrals and when working with other professionals. People, their relatives, and professionals spoke positively about their experiences during initial assessments and when moving to the service. A relative commented, “[Person] is happy here, went for an assessment, has a care plan which is updated every few months.” A professional told us, “I supported someone to have respite and eventually it became a permanent placement. I found the management team to be really lovely and very helpful. They got to know [person’s] needs really quickly and were proactive.” There were processes to share information about people if they had to be admitted to hospital in the event of an emergency. People and their relatives told us health professionals were involved in care when needed, and relatives were kept informed. A person said, “They call the doctor if I need, I see [GP] sometimes.” A relative commented, “They let me know, they always start with ‘everything is ok, don’t worry’ and then tell me."

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately. During the assessment, we identified several safeguarding referrals had not been notified to CQC. This is a legal requirement. We raised this with the provider who told us this was an oversight. Incidents were not always reviewed or signed off by management in a timely way, however, appropriate referrals were made to the local authority in response to safeguarding concerns, and actions were taken to mitigate risk. People and their relatives told us they felt safe living at the service and were confident they could raise any concerns with staff. A relative said, “[Person’s] safe, it feels safe.” Another relative commented, “I know [person] is in a safe place, they are marvellous.” The provider had an appropriate safeguarding policy providing staff clear guidance on how to safeguard people from abuse. The provider told us how they had responded to a recent concern by investigating the incident and taking action to prevent recurrence. Care staff had received safeguarding adults training, understood their responsibilities, and were clear on how to report any concerns. People can only be deprived of their liberty to receive care and treatment when there is appropriate legal authority. In care homes, this is done through a process called the Deprivation of Liberty Safeguards (DoLS), which forms part of the Mental Capacity Act 2005. We found the service was working within the principles of the Mental Capacity Act (MCA) and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. These authorisations were kept under review and monitored.

The provider did not always work well with people to understand and manage risks. The provider had systems and processes to assess and monitor people’s risks; however, these were not always effective. Since the last assessment, improvements had been made in some areas, such as managing risks related to diabetes and catheter care. However, we found further work was needed to improve risk assessments in other areas, such as for people who required a texture modified diet. Care records contained inconsistent information about the food consistency people required, and guidance displayed in the kitchen regarding dietary needs was not up to date. People’s care plans were regularly reviewed by the management team. The move to an electronic care planning system, which was in progress at the last assessment, had been completed. Despite the shortfalls identified, we noted improvements in the level of personalised information and guidance for staff within care records. Staff told us people’s risk assessments contained sufficient information to support safe care. Professionals we contacted who worked with the service were positive about its approach to managing risk. One professional commented, “[Managers] listen to concerns and try to mitigate and reduce risks as best as they can.” People were encouraged to maintain their independence. Staff knew people well and demonstrated an understanding of people’s risks. The provider described how the service supported people to take positive risks through its programme of activities and community outings. The provider acted promptly to update risk assessments where shortfalls were identified.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.We identified some shortfalls in the management of environmental risks. Where oxygen was used within the service, we found environmental risks related to its use had not been robustly assessed and documented. Most areas of the service were being maintained; however, we found some maintenance issues in bathrooms which required attention. Since the last assessment, some areas had been redecorated, including flooring, a communal space, and individual bedrooms. There had recently been changes to maintenance support within the service, with new systems introduced to report and monitor issues, as well as longer-term plans for refurbishment. People using the service, their relatives, and staff told us they were generally satisfied with the environment. However, some feedback indicated some repairs had taken longer to complete due to gaps in maintenance support. The provider carried out other building safety and equipment checks, including gas, fire, and electrical inspections, to ensure the safety of people living in the service. These records were satisfactory. During the assessment, the provider took prompt action to address the shortfalls identified.

The provider made sure there were enough skilled and experienced staff, however, they did not always make sure staff received effective training and development opportunities. We were not assured the systems to monitor staff training were effective, as records were not sufficiently detailed or up to date. While some actions had been taken to address gaps in staff training since the last assessment, we identified other areas not completed or refreshed, such as training on dysphagia, diabetes, and epilepsy. This meant we could not be fully assured staff had completed the training necessary to deliver safe care. The provider told us they had moved from one training provider to another over the past year, which had impacted their record keeping. Despite the shortfalls identified, staff told us they felt supported. A staff member said, “For me, every time I ask for help, they take action.” The provider made use of support from the local authority, which included in-person learning sessions for staff. A professional commented, “I have been in the home many times and delivered a whole array of support teaching sessions.” People and their relatives spoke positively about the support provided and told us there was usually enough staff available to meet people’s needs. A person said, “The staff are brilliant to me, caring, look in on me, make sure I am all right.” A relative said, “There are always staff around.” People were supported by a group of regular, dedicated staff. The provider told us they did not use agency staff, and the team covered absences by taking on additional shifts. Improvements had been made since the last assessment to ensure appropriate staff induction records were maintained and staff received regular supervision. Staff knew people well and engaged in positive interactions. For example, when people showed signs of agitation or distress, staff responded appropriately. Recruitment practices had improved. Staff were recruited safely, with all relevant checks completed before they started working at the service. These included criminal record and employment history checks to ensure suitability for the role.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service was kept clean, and staff followed established infection prevention and control procedures. During our visit, we observed cleaning taking place, staff had access to personal protective equipment (PPE), which was used appropriately. Staff conducted regular environmental walkarounds to help ensure cleaning standards were maintained. We identified some gaps in the cleaning records and raised this with the provider, who assured us this would be addressed. The provider’s infection prevention and control policy reflected national guidance. People, their relatives and staff told us the service was regularly cleaned. A person said, “They keep it clean. They do my laundry too and I usually get my own back.” A relative said, “The home is always clean.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Systems ensured people received their medicines as prescribed. Shortfalls identified at the previous assessment, such as issues with PRN ‘as required’ medicines and guidance for staff on applying topical creams, had been addressed. We reviewed medicines administration records for several people and found recorded stock levels matched the medicines in place. Medicines were stored safely and securely. However, records showed some staff had not refreshed their training and competency assessments within the past year in line with national guidance. We raised this with the provider, and this was addressed during the assessment. People and their relatives told us they were satisfied with the support provided with medicines. A relative said, “They deal with changes of medication and let me know.”