Edgecumbe Lodge Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People were not always safe at Edgecumbe Lodge. Although people were not harmed, we found environmental concerns that posed a health and safety risk to people living at the service. We found a fire exit door in a communal bathroom was not secure or connected to the fire alarm system. This posed a risk to people; in an event of a fire the fire alarm system would not activate. We also found a storage boiler cupboard that was not secure with exposed electrical wires and pipe work. This had not been identified by the manager on their checks of the service. This was rectified by the service after the assessment and photographic evidence was provided. Although the service was clean, we found 2 overflowing bins in communal areas that had not been emptied. This was immediately rectified by the service. The lift was not in operation, and this was impacting 2 people in being able to access the ground floor. However, people told us they felt safe living at Edgecumbe Lodge. Our observations of staff practice raised no concerns. They told us staff were kind and helpful and offered them choice. Staff were trained in safeguarding, nevertheless not all staff demonstrated a good understanding of safeguarding. Staff recorded accidents and incidents and reported them to the relevant professionals. We found the service was working within the principles of the Mental Capacity Act (MCA) and if needed, people had appropriate legal authorisations to deprive a person of their liberty. Any conditions related to deprivation of liberty safeguards (DoLS) authorisations were being met. We found some improvements had been made to the premises since our last inspection and the requirements of a previous warning notice had been met. The service was following a plan for redecoration which began last year and would be completed this summer. Some areas of the home had been redecorated.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe at the service. People looked comfortable and calm with staff who supported them. Comments from people included, “It is all ok as far as I’m concerned. I’ve been here 2 years” and “I’m content here. The food is ok, and the staff are good.” Relatives told us people were happy in the home and the staff communicated with them regarding any concerns they may have. One relative said, “Definitely happy. They phone me on my mobile if there are any problems.

Staff knew how to report accidents and incidents. They reported concerns to the management team. The management team made appropriate safeguarding referrals and reviewed their safeguarding policies on an annual basis. Staff had safeguarding training and understood their responsibilities however, not all staff demonstrated a good understanding of safeguarding.

Staff were attentive and aware of people’s risks to ensure their safety. For example, we observed people being supported to move around the home when this was required. Our observations raised no concerns about staff practice, or the management of people’s risks, and staff had a good understanding of people’s needs

Risk assessment of the lift not being operational and the impact this would have on people was not conducted. This was provided after the assessment. Policies were available to guide staff about how to protect people from the risks of abuse or harm. Senior staff arranged sessions with health professionals to improve staff practice. Staff raised incidents and concerns and reported them to the appropriate professionals when required. People’s capacity to make decisions was assessed and relatives were contacted to ensure decisions made were in the individual’s best interests. The manager had oversight of deprivation of liberty safeguards (DoLS) authorisations and monitored these to ensure they remained up to date and proportionate for each individual

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and relatives told us that the lift was not working; and staff were supporting them to mobilise. One person told us “At the moment, they’ve got problems with the lift being out of order. I can’t get downstairs. With a bit of help I could get there. It’s a bit of a problem for everybody.” This impacted 2 people, they were not able to access the ground floor. People told us they had input in the redecoration of their rooms, however they felt it was taking a long time to complete. The service had a plan for redecoration which had been ongoing since last year. The rooms on the upper floors had all been redecorated alongside the communal lounges. The ground floor rooms were to be redecorated in the next couple of months.

Staff commented on the lift requiring repair and how they were supporting residents to mobilise within the home. The lift had not been operational since December 2023. During the assessment, the provider explained that due to the age of the lift replacement parts were not readily available and need to be manufactured to order, which resulted in a long lead time. The provider told us they were committed to having an operational lift within the service and sent us evidence of obtaining quotes to replace the lift. They informed us about the plan to have a stairlift as an interim measure to support people to mobilise. Staff told us about fire drills held in the home on a weekly basis. They commented on the fire safety training that had been conducted in the home last year. “A couple of months back. We know the procedure; we practice every week.”

At the last inspection, we issued a warning notice because the registered manager had failed to comply with the relevant regulations. During this site visit, we found all the points within the warning notice had now been met. Improvements had been made to the premises. One communal lounge had been refurbished, another had been repaired and reopened. Building works had commenced on a new storage building next to the external office, the provider told us this would address a storage issue within the service. The laundry area had been tiled throughout with a sink being added to prevent the risk of cross contamination. However, we identified some concerns with the premises and environment remained. A fire exit from a communal bathroom on the first floor had a broken ceramic bolt and was not connected to the fire alarm system . This posed a security risk for unauthorised access. The fire exit led to an external steep staircase. Following the site visit the provider sent us photographic evidence the fire door had been secured with a magnetic lock and keypad linked to the fire alarm system. We also observed an unlocked boiler storage cupboard in the second-floor communal bathroom with exposed electrical wires and pipes. This posed a safety risk for people. Following our assessment, the service provided photographic evidence that the cupboard was locked so the risk to any service users gaining entry was mitigated. We did not find evidence that people had been harmed, but this was the shortfall which led to the breach of regulation 15 (premises and equipment), described in the key question commentary above. Although we did not assess the infection prevention and control quality statement, we found the service to be visibly clean, personal protective equipment (PPE) was available and used by staff. We found the lack of an operational lift was impacting on 2 people with mobility difficulties on the first floor. Interim measures were in place, and we saw evidence of this.

Maintenance records were completed but actions undertaken were not always recorded. For example, 1 person had a faulty television in their room. It was noted in the maintenance log that the repair had been conducted, but the television was still not working due to an aerial fault. We observed the interim measures in place to manage the impact of the lift not working, however there was no written risk assessment to assess the potential risks to people. However, following the assessment site visit, the provider submitted a risk assessment and a lift business continuity plan. This detailed the associated risks and the measures put in place to mitigate the impact on people. We were assured by this.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.