Edgbaston Manor

Updated 18 December 2019

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 two inspectors, one assistant inspector, one specialist advisor and one Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Gracewell of Edgbaston is a ‘care home’. People in care homes receive accommodation and nursing or personal care as 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.

This is a dual registered service and Gracewell Healthcare 3 Limited and Gracewell Healthcare Limited are both jointly responsible for service delivery at the location.

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 clinical commissioning group who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with fourteen people who used the service and thirteen relatives about their experience of the care provided. We spoke with eleven members of staff including the registered manager, deputy manager, nurses, care workers and the chef. We spoke with one health care professional who regularly visited the service. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included seven people’s care records and multiple medication records. We looked at two 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.

Updated 18 December 2019

About the service

Gracewell of Edgbaston is a care home providing personal and nursing care to 70 people aged 65 and over some of whom are living with dementia. At the time of inspection 52 people lived at the service. The accommodation is organised into four floors, each with its own communal areas. One of the floors is a memory care floor, specialising in providing care to people living with dementia.

People’s experience of using this service and what we found

People told us they felt safe and staff knew how to recognise signs of abuse and how to report them. People received their medicines as required. Our observations were care staff were available to meet people’s needs. Accidents and incidents were recorded and appropriate action taken to minimise risk to people

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. People told us the food was good and they had a choice of meals. Staff had the skills and knowledge to meet people's needs and referred to healthcare professionals when required.

Some people’s confidential information was kept in cupboards that were not locked, this was addressed on inspection. We saw staff treating people with respect and dignity. Relatives were made to feel welcome in the home and people were involved in decisions about their care. The people we spoke to were complimentary about the service.

People were supported to take part in different activities and where possible activities were person centred and reflective of peoples likes and dislikes. The provider had a complaints process which people and their relatives were aware of to share any concerns. End of life care plans were in place, the service was looking at developing this area further with support from the local hospice.

Systems were in place to monitor the quality of the service although some were inconsistent. People and staff were happy with the way the service was led and the registered manager made themselves available to people. The management team had identified some areas in which they wished to make improvements and had put plans in place to address this. We brought further areas of improvement to the attention of the management team.

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

Rating at last inspection

The last rating for this service was Good (Published 25 August 2017).

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.