Background to this inspection
Updated
3 March 2022
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
As part of CQC’s response to the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. This was a targeted inspection looking at the infection prevention and control measures the provider had in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.
This inspection took place on 8 February 2022 and was announced. We gave the service 24 hours’ notice of the inspection.
Updated
3 March 2022
About the service
St Edmunds is a residential care home providing accommodation and personal care to 37 people. The service can support up to 39 people. The majority of people living in the service were older adults.
The building was large with accommodation over three floors. There were two lifts and two stairwells granting access between the floors. There were variations in levels on all floors which were mostly accessed by means of shallow ramps.
People’s experience of using this service and what we found
Recruitment systems were in place; however, we found some checks on documentation needed to be more robust.
People were supported with their eating and drinking, and care plans were in place which included their preferences and any specialist dietary needs. However, where people were at risk of losing weight documentation needed to be clearer, so external professionals could determine treatment plans. Further training is required so staff understand the importance of this.
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. Some improvements were however needed to ensure that appropriate documentation was completed accurately and contained the most up to date information.
People told us they found their care and support to be safe and were satisfied with the care they received finding staff to be kind and caring. Staff were aware of their responsibility in relation to the reporting of any abuse. Newly appointed staff received induction training and worked alongside experienced members of staff.
People had access to activities provided by an activity co-ordinator. However, some people told us improvements were needed at the weekends, and we have made a recommendation about this.
Care records contained some person-centred information but were not always accurate. Staff were however able to tell us people's current needs and preferences.
There were governance systems in place which included quality audits. However, some had not identified the issues we found and therefore need to be strengthened in some areas. The registered manager and operations manager acted promptly to rectify areas identified as needing improvement, both during and following the inspection.
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 9 May 2017).
Why we inspected
This was a planned inspection based on the previous rating.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Edmunds on our website at www.cqc.org.uk.
Enforcement
We have identified one breach in relation to governance at this inspection.
Please see the action we have told the provider to take at the end of this 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.