Edwina Place

Updated 12 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector. Another inspector made calls to staff to gather their feedback. An Expert by Experience made phone calls to relatives of the people living in the service. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Edwina Place is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Edwina Place is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post. They supported us during our inspection.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Prior to the inspection we looked at all the information we had about the service including notifications the registered manager had sent us. A notification is information about important events which the service is required to tell us about by law. We reviewed the information the provider sent us in the provider information return (PIR). This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke to the registered manager and their line manager. We contacted all staff and spoke to 5 members of the staff team. We observed interactions between staff and people and spoke to 4 people who use the service. We reviewed a range of records relating to the management of the service, for example, records of daily and regular checks for premises and tasks, medicines management, risk assessments, accidents and incidents, quality assurance systems and complaints. We looked at 3 people's care and support plans and associated records. After the site visit, we continued to seek clarification from the registered manager to validate evidence found and received additional documents and information to support our inspection. We spoke to 4 relatives of people living in the service. We also sought feedback from health and social care professionals who engaged with the service.

Updated 12 July 2023

About the service

Edwina Place is a residential home providing personal care and support up to 12 people. The service provides support to people with mental health needs, older people and younger adults. At the time of our inspection there were 9 people using the service.

People’s experience of using this service and what we found

The provider did not always follow their quality assurance systems effectively to assess, monitor and mitigate any risks relating to the health, safety and welfare of people, the service and others. The provider did not always maintain accurate and complete records relating to the management of the premises and management of medicine.

We made a recommendation regarding gathering necessary information as part of provider’s recruitment processes. We made a recommendation regarding having a system to ensure right mix of skilled and knowledgeable staff were on duty. We made a recommendation regarding keeping records to fulfil the requirements of duty of candour.

People told us they felt safe at the service and with the staff and relatives agreed their family members were safe at the service. The registered manager and staff assessed and recorded risks to people and worked with them to mitigate those risks. Staff understood their responsibilities to raise concerns and report incidents or allegations of abuse. People, their families and other people that mattered were involved in the planning and review of their care. Care plans and assessments contained information specific to people’s needs and how to manage any conditions they had. Staff had detailed guidance for them to follow when supporting people with complex needs.

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.

The staff team followed procedures and practices to control the spread of infection using personal protective equipment. When incidents or accidents happened, the registered manager investigated these and identified actions to prevent recurrence and keep people safe. Such events were reviewed and discussed with the staff team. People and relatives told us staff were caring, friendly and kind, and we observed this. Staff understood how to treat people with care, respect, and consideration. Staff upheld people's privacy and responded in a way that maintained their dignity. The registered manager and staff focused on people’s strengths and promoted their independence, so people could achieve desired goals and have a fulfilling everyday life. Staff supported people to access specialist health and social care support in the community. Staff supported people to play an active role in maintaining their own health and well-being, and help achieve good outcomes. Staff supported people to make decisions following best practice in decision-making and respected their rights to refuse support. Staff communicated with people in ways that met their needs. Staff said the staffing levels were sufficient to do their job safely and effectively.

The management team appreciated staff contributions and efforts to ensure people received the care and support they needed. Staff communicated regularly with each other and worked well together. Staff felt they could approach the management team at any time. Staff had support via supervision and appraisals. The registered manager was working with the local authority and different professionals to investigate safeguarding cases and other matters relating to people’s health and well-being. There was an emergency plan in place to respond to unexpected events. There was a process to manage complaints effectively and according to the provider's policy. The registered manager informed us about notifiable incidents in a timely manner.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 21 May 2021, and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Enforcement and Recommendations

We have identified a breach in relation to quality assurance and record keeping such as management of premises and medicine. We have made a recommendation about staff deployment, recruitment records and duty of candour in relation to notifiable safety incidents. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.