Evergreen House Residential Home

Updated 19 May 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 Health and Social Care Act 2008.

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 conducted by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Evergreen House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under 1 contractual agreement dependent on their registration with us. Evergreen House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the 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 (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 8 people who used the service and 4 relatives about their experience of the care provided. We also spoke with 5 staff, the operations assistant and the registered manager. We reviewed a range of records, these included 5 people’s care records, repositioning records, Deprivation of Liberty Safeguards (DoLS) authorisations and medicines administration records. We also looked at governance and quality assurance records and 3 staff recruitment files.

Updated 19 May 2023

About the service

Evergreen House Residential Home is a residential care home providing personal care to up to 38 people. The service provides support to older people, some of whom have physical disabilities or are living with dementia. At the time of our inspection there were 28 people using the service.

Evergreen House accommodates people in 1 adapted building.

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

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Although people's mental capacity had been considered, people's capacity to make specific decisions had not been assessed or recorded. This placed people at risk of having decisions made on their behalf unlawfully. People's lunchtime experience was not always positive. Some people experienced delays in receiving their food and due to the layout of the dining room were unable to leave when they wanted to.

Audits were not always effective at identifying concerns. This included in relation to people’s mental capacity assessments and promotion of people’s rights. The registered manager and provider could not be assured all people were regularly repositioned, as assessed and planned. Staff recruitment records did not consistently evidence staff’s identities or employment histories. Where actions had been identified these were not always promptly undertaken by the provider to drive improvements in people’s care.

People felt safe receiving care at Evergreen House. Risks to people’s safety were assessed and managed safely and there were enough staff to meet people’s needs and act responsively when people needed them. People received their medicine as prescribed and systems used for the management of medicines were safe. Staff followed infection control guidance to reduce the risk of cross infection.

People's needs were assessed and reviewed and the environment was suitable for people's needs. Staff received training and support in their role and had the skills required to support people. Staff understood people's dietary needs and fluid intake was monitored to ensure people had enough to drink.

People described staff as friendly and caring and there was a relaxed atmosphere within the home. People’s independence was promoted by staff who encouraged them to do as much as they could for themselves. People’s privacy and dignity was respected by a staff team who knew them well.

People’s care was planned in accordance with their individual needs and wishes. Staff understood people’s life histories and experiences and supported them with these in mind. People were supported to take part in activities that interested them, although some people felt activities could be tailored more towards their needs. There was a system in place for the management of complaints.

People, relatives and staff spoke positively about the management of the home. People and relatives were confident to give feedback and felt the registered manager took their concerns seriously. Staff expressed confidence in the registered manager and felt supported in their roles. The staff team worked in partnership with others to ensure people’s needs were met.

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 9 January 2021).

Why we inspected

We undertook this inspection to provide the service with a rating in all five key questions.

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.

Enforcement

We have identified breaches in relation to mental capacity assessments and governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.