We are responding quickly to a small number of concerns raised by CQC at our last inspection
People were 'happy and content' living at Edgemont House and we received positive comments about their views and experiences during our visits. People said staff were 'attentive and angels'.
One person said, "I feel like this is my home and I have a big family".
This inspection took place on 12 and 16 May 2016 and was unannounced. There were no concerns at the last inspection of September 2013. Edgemont House is registered to provide accommodation for up to 13 older people. At the time of our visit there were 14 people living at the service. The registered provider had redesigned space within the home to accommodate another bedroom with en-suite facilities. However they had failed to apply to the Commission to increase their numbers and were in breach of their registration conditions.
A manager had been appointed in September 2015; however they had not registered with the Commission. 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.
The home responds: There is now a registered manager in post.
Despite the positive views of people who used the service improvements were required. We could not be satisfied that people were always safe because the care staffing levels did not take into account unforeseen circumstances or emergencies. The way staffing levels were considered needed to be reviewed to take into account dependency levels of people who required care and support
The home responds: Staffing levels have been reviewed and the manager has authority to increase the staffing according to the needs of the residents.
Monitoring the quality of the service had lapsed; they had not been consistently applied and werenot robust enough to ensure quality and safety. People's views and experiences were not sought through quality assurance systems. The provider lacked knowledge and understanding about their legal obligations, including conditions of registration.
The home responds: A new Deputy Manager has been appointed with responsibility for conducting regular audit and satisfaction surveys. These has proved extremely positive.
People were 'happy and content' living at Edgemont House and we received positive comments about their views and experiences during our visits. People said staff were 'attentive and angels'. One person said, "I feel like this is my home and I have a big family".
Staff were knowledgeable in safeguarding procedures and how to identify and report abuse. People were supported by the recruitment policy and practices to help ensure that staff were suitable.
People were helped to exercise choices and control over their lives wherever possible. Where people lacked capacity to make decisions Mental Capacity Act (MCA) 2005 best interest decisions had been made. The Deprivation of Liberty Safeguards (DoLS) were understood by staff and appropriately implemented to ensure that people who could not make decisions for themselves were protected.
People received a varied nutritious diet, suited to individual preferences and requirements. Mealtimes were flexible and taken in a setting where people chose. Staff took prompt action when people required access to community services and expert treatment or advice.
People enjoyed receiving visitors and had made "friends" with people they lived with. They were relaxed in each other's company. Staff had a good awareness of individuals' needs and treated people kindly. Staff were knowledgeable about everyone they supported and it was clear they had built up relationships based on trust and respect for each other.
People moved into the service only when a full assessment had been completed and the registered manager was sure they could fully meet a person's needs. People's needs were assessed, monitored and evaluated. This ensured information and care records were up to date and reflected the support people wanted and required.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We have also made recommendations in the report where improvements are required. You can see what action we told the provider to take at the back of the full version of this report.