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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question inadequate. At this inspection, the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The provider was previously in breach of the legal regulations in relation to premises and equipment. Improvements were found since the last assessment and the provider was no longer in breach of these regulations

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager was aware of their Duty of Candour responsibilities to be supportive, open, and transparent with people and relatives and to apologise when things went wrong. Staff told us they felt able to report incidents and concerns to the manager and senior staff. Staff told us the manager shared information about incidents with the team. One member of staff said, “Accidents and safeguarding are discussed with us.” However, some safeguarding notifications had not been reported to the Care Quality Commission. The manager and nominated individual told us this was an oversight and submitted the notifications during the assessment process.

The provider had procedures to record details and actions following incidents and complaints. The manager kept logs of these to monitor how they were responded to. However, there was no evidence this information was reviewed strategically to identify learning for service improvement or any trends and remedial action to mitigate the risk of these re-occurring. Medicine errors were not always well documented or processed in line with the provider’s policy.

Some people and relatives told us they were involved in assessing and reviewing their care and support needs. One relative told us, “They always let you know what’s going on. They just have a little talk.”

Managers conducted pre-admission assessments and received information about people’s support needs when they received referrals for new placements. This meant they were able to identify if they could support people in the best way. The manager confirmed these initial assessments were used to help develop person-centred care plans for everyone they supported. Staff told us, “When a new resident is coming, we need to read the care plan.”

There had been very few recent admissions to the service, however the provider had systems to promote the safe transition of people from hospital or their own home to the service. However, we identified some risks to people which were not fully assessed to include information from health professionals and provide clear guidance for staff to follow. For example, in relation to catheter care and diabetes, risks had not been fully assessed and documented.

People told us they felt safe using the service. One relative said, “My relative always feels safe and staff support them with their walker.” Another person said, “It’s safe and I have observed them lifting with the hoist.”

Staff received safeguarding training and were able to describe basic safeguarding principles to demonstrate this. Staff were aware of the safeguarding policy and confirmed the process of reporting safeguarding incidents. However, not all staff were able to demonstrate knowledge of Deprivation of Liberty Safeguards (DoLS).

We observed staff acting to ensure people were protected from the risk of harm or abuse. We observed staff interacting with people in a way that promoted their safety and independence. Staff were aware of how to support people in a way that was safe and met their needs. We conducted a SOFI observation which showed positive interactions between staff and people. People were comfortable around staff and interacted warmly with them.

The provider had systems to protect people from the risk of abuse. They had policies to guide staff, such as a whistle blowing policy and a safeguarding policy. The safeguarding policy made clear the provider’s responsibility to report allegations of abuse to the local authority and Care Quality Commission. However, records showed allegations of abuse had not always been dealt with in line with policy. We identified some safeguarding incidents which had been referred to the local authority but had not been notified to the Care Quality Commission. The service submitted the notifications retrospectively during the assessment process.

People told us that staff understood their risks well and offered support to keep them safe. One relative told us, “My relative had 2 falls last year and had a pressure mat put down, to prevent further falls.” People and their relatives told us that they were able to communicate their needs to ensure they received the right type of support. One relative told us, “She always feels safe. The pressure mat rings if she gets out of bed.”

Staff told us they had read people’s risk assessments, and they contained sufficient information about people’s risks. Staff demonstrated their understanding of people’s risks in order to protect people in the least restrictive way. The management team told us they reviewed risk assessments monthly; however, they did not identify inconsistencies and gaps in risk assessments that we identified.

We saw people were supported safely during our time at the service. Staff were timely in their responses towards people to ensure any distress did not escalate. Our observations raised no concerns regarding the management of people’s risks.

The manager told us they were in the process of transferring care plans to an electronic care planning system. Some records completed were sufficiently detailed and person centred; however, we identified some discrepancies and gaps. For example, we found some risk assessments regarding diabetes and catheter care required improvement and further guidance for staff. Following the site visit, the management team took action to update people’s care records.

We saw people’s bedrooms had been personalised to their own tastes. One relative told us, “It’s recently been redecorated. My relative has a new dressing table and mirror.” People and relatives told us that the service was clean, and maintenance issues were rectified promptly, “I’ve raised maintenance queries. When I’m back, the handyperson has done it.”

We observed the service to be clean and communal areas were tidy. Improvements had been made to the premises and further improvement work was ongoing. A maintenance engineer had been employed to ensure improvements were sustained.

We found issues with the premises and environmental risks had been addressed from previous inspections/assessments. The provider had invested in the premises; a new lift had been installed and refurbishment of the dining room and bedrooms had taken place. At the time of the assessment, further improvement works were ongoing. Potential premises risks were monitored by the manager, and documents reviewed relating to environmental checks were satisfactory. The maintenance engineer had kept an action log of maintenance issues which recorded actions taken to rectify issues.

People told us that there were enough competent, skilled staff at the service. A relative told us, “I’ve always found there’s enough staff. There’s always somebody about. If she needs anything, they’re there straight away.

Staff told us there were enough staff within the service and if additional support were required then the manager and deputy would provide this. The management team informed us they did not use agency workers and additional shifts were covered by staff. The management team were aware there were gaps in training and the manager was planning a schedule of refresher training for staff. They had a health professional booked to deliver training to staff.

We carried out observations over 2 days and observed there were enough staff to meet the needs of people. There was an established staff team that knew people well and appeared competent.

The provider told us that they had taken steps to improve training within the service. Healthcare professionals had recently been delivering training sessions onsite. A health professional who delivered training at the service told us, “The team were all very engaged and were very enthusiastic to receive and get involved in all the training sessions.” However, training and induction records were held in several places and there was a lack of clear oversight. Records showed some staff had either not completed or not refreshed training in several key areas such as the Mental Capacity Act (MCA), diabetes and catheter care. We found staff supervision had not been consistently occurring in line with the provider’s procedure. This meant there were gaps in management oversight regarding staff competency and knowledge. The manager told us they had begun supervisions for staff and would be reviewing processes to ensure they take place as required. Recruitment records showed Disclosure and Barring Service (DBS) checks were completed, and references were obtained. For example, staff had regular DBS checks and had been registered for the update service. These check the police database for convictions or warnings that may impact the staff member’s safety to work with vulnerable people. However, recruitment files had not been kept up to date, application forms were not always completed in line with the provider’s policy and gaps in employment history and reasons for leaving previous employment were not always explored and recorded. We could not be assured that safe recruitment practices were being employed. We highlighted this to the manager, who told us they would review and improve all recruitment files.

People told us that the home was kept clean. One relative told us, “It’s clean, we can't complain.” People told us that staff wore personal protective equipment as needed.

Staff knew what personal protective equipment they should wear and when. Staff knew how to put on and remove this equipment, in a safe way. This protected people and staff from the spread of infection.

The home had a dedicated laundry system preventing the risk of cross contamination and people’s laundry being mixed together. We saw adequate hand washing facilities throughout the home available for both staff and visitors. Much of the communal spaces in the building had recently been decorated.

We found improvements had been made since the last assessment in June 2023 with regards to infection prevention, and control. The service had clear processes to ensure people were protected from the spread of an outbreak or infection. Staff had received training in infection control and how to put on and safely dispose of personal protective equipment (PPE). We were assured people were protected against infection by the service having safe systems and following best practice standards. The home had an infection prevention and control policy for staff to follow. This provided staff with guidance about what equipment to use and how to follow safe working practices.

People’s medicines were available and in stock. People who needed their medicine at specific times were given them at the correct time. One person told us, “The staff sort out my medication.” One relative told us, “The medication is all under control.”

Senior staff who administered medicines were able to explain how they supported people to take their medicines safely. One staff member said, “I am confident in giving medicine to people.”

We found medicines errors were not always well documented or processed in line with the provider’s policy. The service had procedures for the safe storage of medicines however, risks relating to the use of emollient creams had not been assessed. Body maps were not used for topical creams and protocols for ‘as and when required’ medication needed further details to guide staff. Staff administering medicines had their competency assessed however, some were out of date. With the exception of 1, stock of medicines held by the service matched records.