Archived: Edwina Mountbatten House

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.

Rating at last inspection: At the last inspection in February 2018, we rated the service as ‘Requires improvement’. That inspection identified two breaches of the Regulations. There had been a failure to ensure that there were strong governance systems in place and records relating to people’s care were not always complete. The provider had also failed to ensure that new staff received appropriate training.

We also made four recommendations. These were:

- That a systematic approach be used to determining the numbers of staff deployed.

- That a more robust pre-admission assessment form be developed.

- That action was taken to ensure that infection prevention and control policies and procedures reflected statutory guidance.

- That staff be provided with training to equip them with the skills they needed to develop end of life care planning with people and their relatives.

People’s experience of using this service:

This inspection found some improvements had been made but many of these were yet to be fully embedded.

The systems in place were not yet being fully effective at identifying compliance with the Regulations and delivering all the improvements needed to achieve a rating of ‘Good’.

People had always received their medicines as prescribed and staff were not always following best practice frameworks in relation to the management of medicines.

Some of the risks associated with people’s care had not been consistently assessed and planned for. Whilst accidents and incidents were documented and investigated. It was not always clear that sufficient action had been taken to reduce similar incidents from happening again.

Whilst planned staffing levels had not always been achieved, people and staff did not feel this had impacted upon the provision of safe care.

Systems and processes were in place to safeguard people from the risk of abuse.

The home was visibly clean and staff followed appropriate infection control measures.

Improvements continued to be embedded to ensure that staff, new to care, consistently received a comprehensive induction mapped to the Care Certificate standards. Staff received regular training opportunities to keep their knowledge up to date.

The registered manager had started to implement an effective and robust supervision programme.

There was a clear focus on the importance of seeking peoples consent, and there was evidence that people were always offered choice and control over the care they received.

Overall assessments of people’s needs were suitably detailed and holistic. Staff were using evidence based guidance to enhance the care provided and to achieve positive outcomes for people.

Where necessary a range of healthcare professionals including GP’s and district nurses had been involved in supporting people to maintain good health.

People told us the environment was homely and comfortable and they were positive about their rooms which they had been able to personalise according to their individual tastes. However, we found that the environment was still not consistently decorated and equipped to a good standard throughout. This had been a concern at out last inspection.

The provider remained committed to the programme of refurbishment which it was hoped would now start in the Autumn. We have made a recommendation about consulting best practice guidance on how to effectively design environments for people living with dementia including the use of appropriate technology, signage and decorating styles.

People continued to be treated with kindness, respect and dignity. Staff understood the importance of supporting people to maintain their independence.

The activities provided were not always well attended and so staff were reviewing these to ensure they reflected people’s known hobbies and interests.

There were systems in place to ensure complaints were investigated and responded to.

Following our last inspection, there had been a number of changes within the management team. The current registered manager had been appointed in August 2018 and there was evidence that they were embedding improvements and that following a period of instability within the staff team, morale was also improving.

Why we inspected: This was a planned inspection based on the rating at the last inspection in February 2018.

Follow up: We will meet with the provider to discuss the findings of this report and will continue to monitor the service closely to ensure the registered manager and provider sustains the improvements already made and improves the rating to at least Good.

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

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At the last inspection, the service was rated overall as ‘Good’. At this inspection we found the service was now rated overall as requires improvement.

Improvements were required to ensure staff were recruited safely and in line with regulatory requirements.

Although some people's care plans provided sufficient detail about how to mitigate known risks, others did not.

Improvements were needed to ensure that medicines were managed safely at all times.

New staff had not completed a training and development programme which helped to equip them with the right skills and knowledge to carry out their roles.

The provider had failed to meet a condition of their registration with the Care Quality Commission by admitting more than the maximum number of service users allowed.

More sophisticated systems were needed to support the registered manager and registered provider to measure the quality of service and delivery of care, treatment and support given to people against the fundamental standards, key lines of enquiry and best practice guidance.

Other areas were good.

There were sufficient numbers of staff deployed to meet people’s needs at this time. The level of dependency of people using the service was increasing however, and so the registered manager would benefit from having a systematic approach in place to determine and review staffing levels. We have made a recommendation about this.

Pre-admission assessments were undertaken but we have made a recommendation about making these more comprehensive in order to support robust decisions about new admissions to the home.

The home was clean throughout, although we have made a recommendation that the registered manager ensure action is taken to fully incorporate statutory guidance in relation to infection control into the policies and procedures within the home.

Staff had received training in safeguarding adults, and displayed a commitment to protect people from abuse. Staff understood their responsibility to report incidents or accidents that could affect the safety and wellbeing of people using the service and these were monitored for trends or themes.

An internal redecoration and refurbishment programme was underway to help ensure the home design and layout met the needs of people using the service.

People’s personal choices and freedoms were respected and people were encouraged and supported to make decisions about their care and support

People were positive about the food provided. People received and were supported to access healthcare services when needed.

People told us they were cared for by kind and caring staff who respected their choices, their privacy and dignity and encouraged them to retain their independence.

People received care that was responsive to their needs. Staff knew people well and had a good knowledge of their likes and dislikes.

People had access to a range of activities and leisure opportunities. People were involved in making decisions about their care and told us they were able to raise any issues or concerns and felt these would be dealt with promptly.

Basic end of life care plans were in place. We have made a recommendation about reviewing best practice guidance to support staff to help people and their relatives feel empowered and positive about talking about death and dying and recording their wishes in relation this.

People spoke positively about the registered manager who had a good knowledge about the people being cared for within the service. The registered manager had fostered a person centred culture within the home.