CQC report explained · a residential care home, run by Serenity Homes
Edgecumbe Lodge Care Home
35 Overnhill Road, Downend, Bristol, BS16 5DS
Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.
What inspectors found, February 2024
Rated Requires Improvement, with Safe rated Inadequate; inspectors found serious risks in the building, fire safety and management oversight.
This was an unannounced inspection on 22 and 26 June 2023. It began as a targeted inspection after health and safety concerns from the local authority. Inspectors widened it to a focused inspection after finding further environmental risks.
The home had some strengths. Medicines were managed safely, there were enough staff, and people had care plans covering their needs. Staff and residents generally spoke positively about the home and its management.
However, inspectors found unsafe premises, fire doors that did not close properly, an out-of-date fire evacuation folder and poor infection control in parts of the building. The home’s checks had not identified these problems. The provider was in breach of Regulations 12, 15 and 17, and warning notices were issued for Regulations 15 and 17.
The overall rating remains Requires Improvement. Safe fell from Requires Improvement to Inadequate. Effective and Well-led remained Requires Improvement. This was the home’s third consecutive Requires Improvement rating.
Medicines
Inspectors found that medicines were stored, administered and checked safely. Staff had completed training and had their competence assessed.
“Medicines were stored, managed, and administered safely. Medicines were administered by staff who had completed training and had their competency assessed.” from the report
Staffing
Inspectors found enough staff to meet people’s care needs. Recruitment checks were generally completed, including interviews, references and DBS checks.
“There were enough staff employed to care for people safely.” from the report
Care planning
People had assessments and support plans covering their personal care, communication, health conditions and preferences.
“The records we reviewed had holistic assessments with individual support plans for people's identified care needs such as personal care, communication, vision and specific health conditions.” from the report
Supportive culture
People and staff gave positive feedback about the manager and the staff culture. One person said they felt safe and that staff were kind.
“One person told us "I feel safe, the staff are kind.” from the report
Fire and environmental safety
seriousSome fire doors did not close properly. Inspectors also found missing window restrictors, frayed cables, trip hazards and other maintenance problems.
“Some fire doors on the ground floor of the home did not close properly.” from the report
Infection control
seriousThe laundry room lacked a full floor covering and a handwashing sink. Broken tiles, unclear laundry storage and worn surfaces made good infection control difficult.
“The laundry room environment had not been updated. The flooring did not cover the whole area and there was still no sink available for staff to wash their hands.” from the report
Weak management checks
seriousAudits and spot checks had not found several problems identified by inspectors. Management oversight was not clear or effective.
“The evidence outlined above demonstrates systems and processes for good governance were not operated effectively.” from the report
Best-interest records
needs fixingCapacity assessments were completed, but records did not consistently explain how best-interest decisions had been made or who had been involved.
“However, we did not consistently see documentation in place which showed how best interest decisions had been reached and who had been involved.” from the report
Relatives’ feedback
needs fixingThe home did not have a system for gathering relatives’ views. Feedback from relatives was mixed.
“There was no feedback mechanism for obtaining views of relatives about the service.” from the report
- 01What work has been completed to make the fire doors close properly, and how is fire safety now being checked?
- 02What repairs have been made to the laundry room, including the flooring, broken tiles, wall and floor seals, and handwashing facilities?
- 03What action has been taken in response to the warning notices for premises and equipment and good governance?
- 04How do you now make sure audits identify environmental, maintenance and infection control risks?
- 05How are relatives’ views collected, and how are best-interest decisions recorded?
This began as a targeted inspection of health and safety concerns and widened to a focused inspection; it mainly examined Safe and Well-led, with infection prevention and control included under Safe. This explanation was written from the published report of 6 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Edgecumbe Lodge Care Home
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- February 2024Requires improvementcurrent ratingstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2021GoodSafe: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- November 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- October 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 13 August 2012.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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