We carried out a review of the data available to us about Edensor Care Centre (Diagrama Healthcare) on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Edensor Care Centre (Diagrama Healthcare), you can give feedback on this 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.
The service is a ‘care home’. People in care homes receive accommodation and nursing and/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.
Edensor is registered to support 48 older people, some of whom may be living with dementia. On the date of our inspection, 41 people were being supported by the service.
At the time of inspection there had not been a registered manager at the service for three months. The deputy manager, who had worked at the service for some years had been employed into the manager role and was in the process of submitting an application for registration.
A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People who were able to speak to us, told us that they were happy living at the service and that they felt supported and cared for by staff. Relatives told us they felt their loved ones were cared for safely.
Staff had received training on safeguarding adults from abuse and understood their responsibilities to prevent people from experiencing harm.
Risks were not always explored in a robust way. Where risk information was gathered, it was not used in a way to inform staff how to best manage and mitigate the risks to people.
The clinical nurse lead and qualified nursing staff managed medicines and medicine audits. However, these audits did not identify concerns we found on the day of inspection. This was mirrored in some safety audits. Whilst safety audits had taken place within correct timescales, checks carried out during this inspection demonstrated that they were not always accurate.
Staff were recruited robustly and safely and extra care had been taken to ensure that those people interviewed could demonstrate the values of the organisation.
The new training coordinator worked with a clear and concise training plan to ensure that staff were up to date with mandatory training. They also had been trained to carry out face to face training in a variety of key areas.
People had access to a variety of choices of food and fluid which were available throughout the day, and were also able to request meals that were not on the menu. Improvements had been made with the meal times and choice. However, this was an area that could continue to be improved, including the meal time experience and the recording of people’s specific nutritional and fluid needs.
We made a recommendation about the meal time experience for people living with dementia.
The provider had made significant improvements in the quality and layout of the service and was in the process of continuing to improve this area. There continued to be issues with cleanliness.
The staff were caring. They knew people well and were sensitive to their needs. People were encouraged to be as independent as possible and staff treated them with dignity and courtesy.
The manager and activity coordinator had worked tirelessly to improve the quality of activities provided to people and demonstrated continuous drive to ensure that all people living at the service had access to various opportunities and experiences. This included some innovative and creative thinking about how to engage external organisations and the local community. However, the activity coordinator only worked during the week during office hours, and staff working at the service did not always involve people in activities in their absence. The service was in the process of recruiting an additional part time activity person, however, there was a need for shift co-ordinators to motivate staff to engage with people in a meaningful way.
People and staff completed yearly satisfaction surveys. The manager was not able to tell us how the information had been used to develop the service further.
Information on how to raise concerns or complaints were available and people and their relatives were confident that any concerns would be listened to and acted upon.
People’s care plans were cumbersome and difficult to navigate through. Care plans audits were completed but did not always demonstrate that appropriate review had taken place. There was little evidence that people had been involved in planning their care.
We have made a recommendation about planning of people's care.
The provider had been very responsive to concerns raised at the previous inspection and had taken action to improve the service. This included staff engagement, conditions of employment and opportunities to develop. The manager was approachable and staff felt able to share views and concerns. However, the leadership at the service was in the process of development following the registered manager leaving in June 2018 and deregistering with the commission in August 2018.
This area needed improvement, particularly at clinical lead and registered nurse level and the home manager oversight of care provided.
We have made a recommendation about leadership.
Following the inspection, the manager told us about changes that they intended to make to improve the service. However, we continue to have concerns that the governance systems
had not identified the concerns found at inspection.
During this inspection we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the end of this report.
This service is a nursing and residential home for up to 50 people who have nursing, and physical and mental health needs. At the time of inspection 43 people were living at the service which was set out over a number of areas in the building. The flat, downstairs, and the second and third floor.
There was a registered manager in place at the time of inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We found that the service was safe. Good recruitment processes were in place with values based interview questions and all necessary pre-employment checks had been carried out on staff.
Medicines were stored and dispensed safely and people’s physical needs, including nursing interventions were carried out in a timely and safe way.
People with complex and challenging behaviours were cared for by staff that knew them well and who supported them with compassion. However, documentation that was specific to behaviours that challenged needed improving to evidence what people told us about the care they received.
Staff had received training to recognise signs of abuse and knew how to act upon concerns.
Dementia and sensory impairment training was needed for staff working with people living with these disabilities. The consequence of not having this training was witnessed in some of the interactions with staff which needed improvement in order to support people to live well with these difficulties.
Some peoples opportunity for social interaction and stimulation was limited meaning they were at risk of social isolation. The management team acknowledged that additional work was needed on the provision of activities for these people.
People received a good choice of food and could request alternatives at any time. People with specific dietary needs were catered for well.
Staff understood the Mental Capacity Act and the importance of this within their everyday interactions with people living at the service.
Staff were caring and respected peoples dignity, privacy and confidentiality.
Care plans were person centred and easy to navigate through, although some people said they did not get involved in the planning of their care.
Loved ones of people living at the service felt they were listened to and if they had a complaint the management team and staff would put it right.
The new provider and existing management team kept people and their loved ones up to date with changes at the service. They also acted as positive role models in all interactions with people and relatives.
Robust systems were in place to investigate incidents and accidents and disseminate learning from these to the staff team.
Clinical governance processes were good and we saw that these were being appropriately used to monitor and manage the quality of care and any potential risks at the service.