Edwina Place

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.