Evergreen

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, underpinned by openness and honesty. Staff listened to and acted on concerns about safety and understood their responsibilities to report incidents and safety events appropriately. These were investigated, recorded, and reported, and learning was used to improve practice.

There was a positive learning culture within the home. The registered manager was receptive to feedback and used this to proactively develop and improve the service. They worked closely with staff and maintained clear oversight of accidents and incidents. Where learning was identified, actions were taken to reduce risk and strengthen practice, supporting continuous improvement

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager undertook thorough pre‑assessments to ensure the service could meet each person’s needs before they moved in. Follow‑up assessments were then completed after people moved in and began to settle in the home, this meant people’s needs were accurately understood, and any risks were identified early.

The registered manager worked closely with staff to identify and respond to any changes to people’s health. Concerns were escalated promptly and referrals completed to appropriate health professionals, such as occupational therapists (OT), GPs, speech and language therapists (SALT) and wound care specialists. When people were admitted to hospital the registered manager and staff ensured all appropriate information was available to ensure a smooth transition.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff had access to safeguarding information and completed safeguarding training. Staff demonstrated a good understanding about identifying and reporting concerns. One told us, “I would raise any concerns with the manager, and they would refer it straight away, but I could raise it myself if I felt I needed to.”

People felt safe living at Evergreen. One told us, “I have been here a long time, staff are nice, I do feel safe.” The registered manager reviewed safety events and took appropriate action. This included referrals to other agencies when required.

People’s mental capacity had been considered. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We saw best interest decisions had been recorded including conversations with people’s next of kin (NoK) or Power of attorney (PoA) when appropriate. The service was working within the principles of the MCA and if needed, DoLS authorisations were in place to deprive a person of their liberty.

The provider worked with people to understand and manage risks by taking a holistic approach. Staff provided care to meet people’s needs in a way that was safe, supportive and enabled people to do the things that mattered to them. People were supported to maintain their independence and risks were identified and managed safely without imposing undue restrictions on people.

Risk assessments were in place for people's identified needs and were reviewed regularly to ensure people’s safety was maintained. Where people had specific health conditions, such as Parkinson’s disease, diabetes, or other complex health needs, relevant information was recorded and discussed during handovers. This ensured staff knew people well and care was delivered safely and effectively.

People were supported to take positive risks to enhance their quality of life while balancing safety.

Care was personalised and tailored to each person's individual needs. This ensured staff had the information needed to deliver consistent and effective care and people were supported to manage risks safely while continuing to lead full and rewarding lives.

Personal emergency evacuation plans (PEEPS) were recorded to support safe evacuation in the event of a fire or other emergency. These included any details of any equipment or support people would require to evacuate safely.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The home was well maintained and had a welcoming and homely feel. People were able to personalise their rooms. One person told us, “I like it here, I was worried before I moved in that it was going to be all chandeliers and plush carpets. I have been in homes that are like that and they are not always good. It is normal here, and it feels comfortable here it’s a really nice place to live.” Relatives told us, It’s a small nursing home, it is really different from the other places we have been. Its more personal here.”

Equipment was in place for people’s needs, including electronic hoists, assisted baths, and mobility aids. All equipment and services were regularly maintained. Fire safety checks were carried out and equipment was in place to assist with safe evacuation from the home.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were staff available at all times to ensure people received the care and support they needed. We saw that staff responded to people’s needs promptly.

Many of the staff had worked at the home for several years. Staff spoke positively about their role and felt supported by the registered manager. Staff worked well together as a team and told us they loved their job and enjoyed working at Evergreen.

Staff were safely recruited; this included an induction and shadowing experienced staff. Staff undertook regular training updates and told us they received the training they needed to meet people’s needs safely. When a person's needs became more complex, further training was provided to ensure staff could safely meet their needs Registered nurses (RN’s) received specific training to ensure a person's nutritional needs could continue to be met via an enteral feeding system. A regular visitor to the home told us, “The staff had skills to support [persons name] safely, I often heard them talking about training, their confidence stood out.”

Staff supervision was taking place but not on a regular schedule. However, all staff we spoke to told us they felt supported. We saw the registered manger was very hands on and worked alongside staff. Staff were able to speak to the registered manager at any time.

The provider assessed and managed the risk of infection. They took appropriate action to detect and control the risk of infection spreading and shared concerns with relevant agencies when required.

Staff shared the domestic duties and the registered manager completed daily checks to ensure all cleaning tasks had been carried out. Staff had access to personal protective equipment (PPE) and we saw staff using this appropriately.

The home had recently received an infection protection control (IPC) champion and accreditation award. Staff documented daily cleaning and regular deep cleaning was carried out. Audits and checks had been completed to ensure infection prevention control measures were maintained.

People told us, “My room is kept nice, always staff popping in and out to tidy and do things.” Relatives told us they always found the home to be clean and tidy.

Health professionals told us, “The home appears clean, tidy and well-maintained whatever time of my visit.”

The provider ensured that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning their care, including when changes to medicines occurred.

There were safe medicines systems and processes in place. Registered nurses (RNs) were responsible for administering medicines and had completed appropriate training and competency assessments. This ensured their knowledge and skills supported best practice and demonstrated a good understanding of people’s medicines.

People had access to pain relief when required. We observed RNs checking with people to see if they needed ‘as required’ (PRN) medicines including pain relief. Clear guidance was in place to support staff to understand why PRN medicines were needed and how they should be taken. Records were completed to show if the medicine had been effective. For people on medicines which required regular monitoring, we saw these checks were carried out to ensure medicines were dosed appropriately.

Medicines were regularly reviewed and audited. This included external auditing by the medicines optimisation for care homes (MOCH) team.