Edgecumbe Lodge Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Staff felt supported and listened to by management. They had regular supervisions and appraisals. We found some improvements had been made to the service’s quality assurance systems since our last inspection, but further improvements were required. Audits had not been consistently completed and reviewed by the management team to ensure sufficient management oversight. The service had not notified the Care Quality Commission (CQC) about the absence of the registered manager which they are legally required to do. In addition, the registered manager had not submitted a CQC Provider Information Return (PIR) since 2021. This is meant to be completed each year. There was no written risk assessment in place regarding the impact of the lift that was not operational. This was rectified during the assessment. These areas all contributed to a breach of Regulation 17 (Good Governance).

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us they received sufficient support from the management of the service. They informed us about team meetings held every 3 months. They found the deputy manager and provider approachable. One staff member said, “I can speak to the deputy manager and provider. We have a staff what’s app.” Staff were able to tell us that supervisions they had every 3 months and appraisals every 6 months. They informed us that staff morale was good and that everyone worked together as a team.

Senior staff had implemented some quality assurance systems however, we found audits were not consistently completed. For example, the falls audit had not been completed for 5 months. The legionella checks had not been undertaken since November 2023 and the fire blanket check had not been completed since March 2023. This demonstrated lack of management oversight over health and safety. There was no written risk assessment or contingency plan for the lift breakdown to show how risks and impact to people were assessed and managed. These shortfalls led to a breach of regulation 17 (Good Governance) as described in the key question commentary above. There was currently no registered manager in post, and the Care Quality Commission (CQC) had not been formally notified of their absence which they are legally required to do. The provider told us recruitment for a new registered manager was ongoing and provided us with a plan for the day-to-day management of the service which provided sufficient cover. The provider had not submitted information which is requested annually by CQC. This was last received from the service on 3 November 2021. The provider told us they had not received the request due to changing their email provider. Following the assessment the provider confirmed they had updated their contact details with CQC. The provider told us they had been receiving support from a local social care body, Care and Support West, since the last assessment and employed a Project Manager 2 days per week to improve their management systems and processes. We were told progress had recently been impacted by the changes of registered manager.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.