Background to this inspection
Updated
5 February 2020
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.
Inspection team
The inspection team consisted of one inspector.
Service and service type
Edensor 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.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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 used all this information to plan our inspection.
During the inspection
We spoke with six people who used the service and three relatives about their experience of the care provided. We spoke with nine members of staff including the provider, registered manager, two nurse clinical leads, a senior care worker, care workers and a member of the housekeeping staff.
We reviewed a range of records. This included four people’s care records and medication records and variety of records relating to the management of the service. This including policies and procedures were reviewed and how the service monitored the quality of care provided. We also looked at information relating to staffing and how they were inducted and trained and training data and quality assurance records.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We spoke with two professionals who regularly visit the service and two commissioners.
Updated
5 February 2020
About the service
Edensor is a residential nursing home, registered to support 48 older people in one building, some of whom may be living with dementia. On the date of our inspection, 34 people were being supported by the service.
People’s experience of using this service and what we found
Staff had a good understanding of how to protect people from abuse and policies and processes in place protected people.
People were supported by staff who understood the risks to their health and well being and how to mitigate these safely.
Medicines were stored and managed safely by competent nursing staff who carried out regular medicine audits.
The environment was safe and regular checks ensured this remained so.
Staff respected people’s right to choose how they were supported. Staff understood the principles of the mental capacity act 2005 and how to apply them.
People enjoyed good meal time experiences by staff who understood their nutritional needs and risks to people’s physical health.
The provider had invested in staff training which had a focus to improve person centred care provision, for those people living with dementia. Systems in place ensured staff remained updated for mandatory training.
Staff at all levels were exceptionally caring, and often went the extra mile to ensure people and their loved ones felt cared for. Staff respected people’s privacy and dignity and care practices supported this.
People were cared for by staff who understood the importance of individualised person-centred care. Training provided to staff focused on working with people’s strengths and being creative to manage those areas that caused distress.
The provider had created a service which ensured people had access to excellent activity staff who planned meaningful and engaging activity to promote independence and mitigate social isolation.
The registered manager and clinical leaders had worked hard to make improvements at the service and had robust action plans to continue to enhance people’s quality of lives.
Systems and processes in place to monitor the quality of the environment had improved and there was good oversight from the registered manager, provider and clinical leaders.
The service was open and transparent and worked well with external health care professionals, constantly seeking how to improve the care they provided.
Staff, people and relatives told us the service was well led and managers were visible, approachable and would act on any concerns they raised.
MCA all reports
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.
Rating at last inspection and update
The last rating for this service was requires improvement (published 24 October 2018) and there were two breaches of regulation. This was the second requires improvement rating for this provider. 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 improvements had been made and the provider was no longer in breach of regulations.
At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.