Archived: Edgbaston Manor

Updated 14 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection was undertaken by one inspector.

Service and service type

Edgbaston Manor is a ‘care home’. People in care homes receive accommodation and nursing 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.

The service had a manager registered with the Care Quality Commission. This means that they and the nominated individual are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from the local authority and professionals who regularly visit the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

This information helps support our inspections. We took this into account when we inspected the service and made the judgements in this report. We used all this information to plan our inspection.

During the inspection

We spoke with 8 people and 5 relatives about their experience of the care provided. We also reviewed compliments, nomination cards and surveys, which gave us further insight into the quality of people's care and what it was like to live or work at Edgbaston Manor. We spoke with 6 members of staff including the registered manager, a deputy manager, the chef and 4 care workers.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included 6 people’s care records and multiple medication records. We looked at 6 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data, quality assurance records and policies. We spoke with 2 healthcare professional who regularly visit the service.

Updated 14 July 2023

About the service

Edgbaston Manor is a residential care home providing personal care for up to 70 older people and some of those people are living with dementia. At the time of inspection 59 people were living in the home. The property is purpose built. Bedrooms are en-suite and the home has additional facilities including a hairdressers and entertainment rooms.

There are usually nine staff on day shifts including deputy managers, a chef, as well as the registered manager. Nights are covered by three staff with management on-call as required.

People's experience of using this service and what we found

Staff used an electronic system to record the contact and support given to people. This meant that staff coming onto shift had access to up-to-date information about the care and support provided. Care plans and risk assessments identified people's support needs and staff had a good understanding of the support people needed.

Feedback about the service, from people who lived at the home and those close to them, as well as professionals who often visited was consistent and positive. People and relatives praised the staff, the facilities and management.

Distinctive leadership decisions about activities and inclusive decision-making with people who lived at the home had achieved a service that was responsive. The service was innovative and made great effort to give people a person-centred care experience which led to positive outcomes. People and their relatives were encouraged to be involved in care planning and reviews.

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.

People were treated with kindness and compassion. People felt well-supported. People were listened to and could express their views. People's privacy and dignity was maintained.

People, relatives and staff expressed confidence in the registered manager, and were given the opportunity to provide feedback. Audits took place to ensure the quality of the service was maintained.

People, staff, and relatives knew how to complain. The registered manager understood their responsibilities under the duty of candour.

For more details, please see the full report for Edgbaston Manor which is on the CQC website at www.cqc.org.uk

This service was registered with us on 10 December 2021 and this is the first inspection.

Why we inspected

This was a planned inspection because this service is unrated.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.