Evelyn May House

Updated 25 January 2022

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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by three inspectors.

Service and service type

Evelyn May House 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 who was not yet registered with the Care Quality Commission. This means that they and the provider 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 inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with ten people who used the service and eight relatives about their experience of the care provided. We spoke with four members of staff including the manager and regional manager, and three care staff.

We reviewed a range of records. This included five people’s care records and medicine records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including audits, training information and action plans.

Updated 25 January 2022

About the service

Evelyn May House is a care home providing personal care and accommodation for up to 59 people. On the day of inspection, 56 people were using the service. The service does not provide nursing care.

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

People and relatives mostly told us they had positive experiences of the service. One relative told us, “Staff are amazing so happy and patient in their work.” One person told us, “I have met some lovely people here. I enjoy knitting and being up and about with my friends.”

Documentation in care plans did not always contain all the information staff needed to support people safely. Some information required more detail to provide person centred care. Where information was in care records this was not always followed safely.

Systems had been put in place to make improvements to safeguarding referrals to the local authority where required for investigation. There was enough staff available to support people who had been safely recruited. Medication was managed safely by staff.

The manager was actively working to review the service and make improvements where needed. Systems at the service where being developed to provide oversight.

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

Rating at last inspection The last rating for this service was good (published 21 November October 2019).

Why we inspected: We received concerns in relation to staffing levels. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Evelyn May House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.