Background to this inspection
Updated
14 April 2021
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 Care Act 2014.
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
This inspection was carried out by two inspectors.
Service and service type
Edwina Mountbatten House is a ‘care home’. People in care homes receive accommodation and nursing 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.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
We gave the service 48 hours’ notice of the inspection. This was because we were mindful of the impact of the COVID-19 pandemic on services.
What we did before the inspection
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We reviewed information we had received about the service since the last inspection. We used all of this information to plan our inspection.
During the inspection
We spoke with two people who used the service. We reviewed a range of records, which included multiple medicines records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We sought feedback from eight relatives about their experience of the care provided. We spoke with eight members of staff including the registered manager, senior care workers, care workers, administrators and domestic staff. We reviewed nine people’s care records. We looked at training data and quality assurance records. We sought feedback from two social care professionals who work with the service.
Updated
14 April 2021
About the service
Edwina Mountbatten House is a residential care home providing personal care to 16 people aged 65 and over at the time of the inspection. The care home can support up to 17 people, some of whom may have dementia. People are accommodated in one building, which is arranged over two floors and surrounds a courtyard. The registered provider is The Countess Mountbatten of Burma Memorial Trust, a registered charity run by a board of Trustees.
People’s experience of using this service and what we found
There were areas where infection control practice needed to be improved to reduce the risk of infection and keep people safe.
Improvements were needed to ensure that the premises were fully secure and did not present risks to people. The provider has taken the required action to address these since the inspection.
Medicines were well managed overall, and people received their medicines as prescribed. We found some areas where medicine practice could be improved.
We were assured that there were enough staff to meet people’s needs. Staff had been recruited safely.
People’s relatives told us they felt confident that their family members were safe.
Staff knew residents well and provided support in an attentive and kind way.
We were not assured that systems in place to monitor the service, reduce risks to people and drive improvement were fully effective.
Records relating to people’s care were not always accurate or up to date. This had not been identified by quality assurance systems.
We saw that the provider had invested in refurbishment to improve the décor of the building.
People and their relatives were able to give feedback about their care and this was acted upon.
People’s relatives felt the service had kept them informed throughout the COVID-19 pandemic and spoke positively about the leadership team.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 30 April 2019). That inspection identified a continued breach of the Regulations regarding good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found that although some improvements had been made, the provider was still in breach of regulations.
The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections. We will describe what we will do about the repeat requires improvement in the follow up section below.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 25 March 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance.
We undertook this focused, short notice inspection on 29 January 2021 to check that the provider had followed their action plan and to confirm they now met legal requirements. The inspection was also based on the previous rating. This report only covers our findings in relation to the Key Questions 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 coronavirus and other infection outbreaks effectively.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection. Please see the Safe and Well-led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Edwina Mountbatten House on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.
We have identified breaches in relation to infection prevention and control and governance at this inspection.
Please see the action we have told the provider to take at the end of this full report.
Follow up
We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.