Archived: Edge Brook

Updated 6 September 2023

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 Health and Social Care Act 2008.

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 2 inspectors.

Service and service type

Edge Brook is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Edge Brook is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because the service is small and people are often out and we wanted to be sure there would be people at home to speak with us.

Inspection activity started on 26 July 2023 and ended on 22 August 2023. We visited the location’s service on 26 July 2023.

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. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 3 people and 1 person who had recently moved from the service to understand their experience of care and support provided. We also spoke to 3 relatives. We spoke to 7 staff including the nominated individual, the registered manager, the deputy manager and senior support and support workers. We also spoke with several professionals who work closely with the service. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records including 2 people’s care records, medication administration records and associated documentation. We also looked at other records relating to the management of the home and risk management. We looked at safety information and certificates, staff rota’s, accident and incident forms, meeting minutes, audits and policies. We also reviewed 4 staff files in relation to recruitment, staff supervision, competency assessments and training.

Alongside our visit to the service, we used remote technology such as video calls to enable us to engage with staff and electronic file sharing to enable us to review additional documentation.

Updated 6 September 2023

About the service

Edge Brook is a small ‘care home’ providing accommodation to up to 6 people who require nursing or personal care. The service provides support to young people with an eating disorder. At the time of our inspection there were 4 people using the service.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

At the time of the inspection, the location did not care or support for anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.

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

Right Support: People were supported by staff who had a strong understanding of how to promote people’s independence. Staff supported people to work towards achieving their goals by working in accordance with robust care plans. People told us they felt support relating to 1 to 1 support and engagement could improve; we discussed this with the provider who was able to evidence this was consistently under review. People were able to personalise their rooms with personal items important to them. The provider was able to evidence the approach staff took in supporting people during times of anxiety and distress was consistently reviewed and reflected on to inform continuous improvement.

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.

Right Care: People received robust support relating to their diet and when support from external professionals was needed, this was requested in a timely manner. Feedback from people and some relatives was mixed in relation to how safe people felt at the service. Staff’s presence within the home was consistently raised as needing improvement particularly comments relating to staff spending significant periods of time in the office. We also observed during our visit to the service staff spent long periods of time based in the office; however, we also noted there was generally one member of staff based in the areas of the home most frequently used by people. We discussed feedback with the provider who provided evidence of reflective work around this issue; we have made a recommendation the provider carries out further work to respond effectively to people’s feedback around feeling safe.

Right Culture: The provider ensured a person centred approach to care planning, support and care was promoted throughout the service. People’s protected characteristics were considered at all times. The provider had robust quality assurance systems in place which ensured checks within the service were robust and accurate. The provider had worked proactively with local safeguarding professionals to ensure they were meeting the requirements to share safeguarding incidents in line with local and national guidance and legislation. We observed evidence of reflective work being carried out. However, in some cases this was not always recorded in relevant records; for example, management reflection on accidents and incidents needed additional detail to evidence why staffs approach to supporting people, during periods of anxiety and distress, reflected best practice particularly in relation to people’s therapeutic plans. We have made recommendation relating to reflection in accidents and incident and in relation to people feeling included in decisions made about their support.

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 good (published 28 May 2023).

Why we inspected

We received information which highlighted a review of risk management and service governance was needed. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained the same.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe, effective and well-led sections of this full report.

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 COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Edge Brook on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.