Evergreen Lodge

Evergreen Lodge is a care home that provides accommodation for up to 40 people who need help with nursing and personal care. At the time of our inspection 28 people lived in the home. Some people living in the home lived with dementia or other mental health issues.

At our previous inspection in December 2019 the provider was in breach of regulations. At this inspection we found enough improvements had been made and the provider was no longer in breach of regulations. However, evidence that could be reviewed was limited as these improvements had been implemented following a change in management after the last inspection. The focus now needs to be on further embedding and sustaining improvements over a longer period of time in order to achieve an overall rating of good.

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

People and their family members told us they had seen improvements in the quality of care and support people received at Evergreen Lodge. One family member told us, “Since [Name] has become registered manager, we have noticed improvements in the environment, structure, communication and all standards.”

Risks to people were assessed and their safety was monitored. Regular checks were carried out on the safety and cleanliness of the environment and equipment and prompt action was taken to mitigate any risk identified. Risks in relation to aspects of people's direct care was assessed and measures put in place to guide staff on how to keep people safe. People’s safety was monitored, and outcomes recorded in line with risk management guidance.

Medicines were safely managed by staff with the right training and skills. Medication administration records were kept up to date with details of people’s prescribed medicines and instructions for use

People were safeguarded from the risk of abuse. People told us they felt safe and were treated well and family members told us they were confident their relatives were safe. The registered manager and staff were knowledgeable about the different types and indicators of abuse. Allegations of abuse were managed in line with the providers and the local authority safeguarding procedures. Clear records of incidents of a safeguarding nature were maintained.

The providers systems and processes for assessing, monitoring and improving the quality and safety of the service were used effectively. Checks and audits were completed in line with the providers quality assurance framework and areas for improvements were identified and action taken. Records were regularly reviewed, kept up to date and checked for accuracy.

People, staff and family members told us they were engaged and involved in the running of the service and they were provided with opportunities to feedback about their experiences of the care provided. Family members and staff spoke positively about how well the service was run and the improvements made since the registered manager had been in post. There was good partnership working with others including external health and social care professionals.

Risks relating to infection prevention and control (IPC), including in relation to COVID-19 were assessed and managed. Staff followed good infection, prevention and control (IPC) practices.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 15 January 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

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

Why we inspected

A decision was made for us to inspect, examine and follow up what improvements had been made since the last inspection in December 2019. Due to the COVID-19 pandemic, we undertook a focused inspection to only review the key questions of Safe and Well-led. Our report is only based on the findings in those areas reviewed at this inspection. The ratings from the previous comprehensive inspection for the Effective, Caring and Responsive key questions were not looked at on this occasion. Ratings from the previous comprehensive inspection for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

Follow up

We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

This service has been in special measures since April 2019. During this inspection, the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in special measures.

Evergreen Lodge is a care home that provides accommodation for up to 40 people who need help with nursing and personal care. At the time of the inspection 33 people lived in the home. Most of the people living in the home lived with dementia or other mental health issues.

People's experience of using this service:

At the last inspection, the provider was rated inadequate. At this inspection, the rating has remained the same. This was because people did not receive safe care in all aspects of their care and the management of the service still needed significant improvements to be made.

During the inspection, the manager and the provider did not demonstrate they had sufficient oversight of the service and the support people received. They did not demonstrate they understood their regulatory and legal requirements with regards to the service. We found that there were no adequate or effective systems in place to monitor some aspects of the quality and safety of the service. This resulted in people being exposed to ongoing risks.

People’s needs and the support they required were planned for, but people did not receive safe nursing care in accordance with their care plan. Some nursing tasks were also completed by care assistants on the request of nursing staff without appropriate training or authority to do so. The manager and provider were unaware of this practice. They acted on this immediately when it was brought to their attention during the inspection.

Where improvements in people’s care were identified by the manager, these had not been acted upon by staff or followed up by the manager to protect people from harm.

Medication management was unsafe and placed people at significant risk of harm. People did not receive their medicines as prescribed or, in the correct way at all times, by nursing staff.

After the inspection, we referred several people to the local authority safeguarding team as we had serious concerns about the care they received.

At the last inspection concerns were identified with regards to staff recruitment, training and support; the unlawful use of restraint, obtaining people's consent to their own care, safeguarding and the identification of people’s needs and risks. We found that sufficient improvements in these areas had been made.

People were supported to have as much choice and control of their lives as possible. Improvements in the way in which staff responded to people’s emotional well-being meant that the need for, and use of, restrictive practices had reduced. People were now supported in their best interests in accordance with the Mental Capacity Act 2005 (MCA).

People received enough to eat and drink and were given a diet suitable for their needs. People told us they had a choice and that the food and drink was of satisfactory quality.

Staff recruited since the last inspection were recruited safely. Staff training had been updated and the number of staff on duty was sufficient to meet people’s needs.

People were encouraged to join in a selection of activities available in the home, as well as pursue their own personal interests and hobbies.

The service worked in partnership with a range of other health and social care professionals to ensure people had access to other healthcare services.

Relatives told us they were always made welcome and we saw that the feedback and suggestions of people living in the home and their relatives were sought.

The home was adequately maintained. The atmosphere was calm and homely and staff were kind and patient. It was clear staff knew people well and talked to people socially whilst offering support. This was good practice. People told us they felt supported and that had no complaints about the home or the staff team.

The manager and provider were open and transparent during our inspection and acknowledged that significant improvements needed to be made. They displayed a committed attitude to making those improvements in a timely manner.

Rating at last inspection and update:

The last rating for this service was inadequate (published 07 June 2019) and placed in special measures. At this inspection, the rating has remained the same. This is because although some improvements had been made, the service remained in breach of regulations 12 (Safe care and treatment) and 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

After this inspection, the provider completed an urgent action plan to show us what they would do immediately to improve the safety of the service and protect people from risk.

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

On the request of CQC, the provider agreed to submit a monthly update on the improvements they will continue to make with regards to the service.

These monthly updates will help CQC monitor the home’s ongoing progress towards meeting the health and social care regulations to a good standard.

We will also meet with the provider following the publication of this report to discuss how they will make changes to ensure they improve their rating to at least good.

On the request of CQC, the provider has agreed to submit a monthly update on the improvements made. These monthly updates will help CQC monitor the home’s ongoing progress towards meeting the health and social care regulations to a good standard. We will work with the local authority to monitor progress.

We will also continue to monitor the 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.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service will remain in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

People’s experience of using this service:

The overall rating for this service is ‘inadequate’ so therefore the service is in special measures. During our inspection we found breaches of regulations 9, 11, 12, 13, 17 and 19 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were no adequate or effective systems or processes in place to monitor the quality and safety of the service. This resulted in people being exposed to ongoing risks with regards to their care.

Some people’s needs and risks were not properly assessed or care adequately planned. Information on people’s preferences and wishes with regards to their care was also limited. Records showed that some people did not always receive the care they needed in accordance with their care plan.

Some people lived with behaviours that challenged due to issues associated with their mental health. We found that staff had little guidance on how to support the person appropriately when these behaviours were displayed so that risks to the person or others, were minimised.

We observed that restraint techniques were commonly used to manage people’s behaviours and movements. These techniques had not been risk assessed, formally agreed upon or legally authorised by following the Mental Capacity Act 2005 (MCA). This meant the techniques in use were unlawful. There was also no adequate system in place to monitor and manage the use of this restraint. This placed people at risk of significant harm.

Some people had deprivation of liberty safeguards in place and we saw some evidence that the MCA had been followed with regards to this. However consent for other decisions in relation to people’s care had not. For example, decisions relating to the administration of covert (hidden) medication and do not resuscitate orders were not made in accordance with the MCA to ensure people's consent was legally obtained.

We found the management of medication to be unsafe. It did not comply with best practice guidelines from the National Institute of Social Excellence (NICE) or the Royal Pharmaceutical Society.

Robust recruitment procedures were not always followed when recruiting new staff. The provider’s staff rotas showed that sometimes they were one staff member short but people told us there were enough staff on duty to meet their needs.

The majority of staff had completed sufficient training to do their job and had received supervision from their line manager. Staff members told us they felt supported in their role.

During our inspection, we observed that staff interacted with people respectfully and were patient when providing support. They chatted to people socially and people were observed to be relaxed and comfortable in their company.

People told us they had enough to eat and drink and said the food was satisfactory. People’s special dietary requirements were catered for and people had a choice of what to eat and drink.

People told us staff were kind and that they felt safe living in the home. Relatives we spoke with confirmed this and spoke positively about the staff team and the manager.

There was a range of activities for people living in the home to become involved in and their feedback about the activities was positive.

The home was adequately clean, maintained and suitable for the people who lived there.

Rating at last inspection: The rating at the last inspection was good. At this inspection, the rating has not been maintained.

Why we inspected: This was a scheduled inspection.

Enforcement : We are currently considering what action we need to take with regards to the serious concerns we identified at this inspection.

Follow up: Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures

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

At the time of the inspection, the home had a manager who was registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

The people accommodated at Evergreen Lodge were living with dementia-related conditions or had other mental health needs. Some people had challenging behaviour and required one to one support from staff to ensure their safety and/or the safety of others. We observed that people were treated with dignity and respect and support was provided in a non-judgemental manner.

The manager and staff had knowledge of the Mental Capacity Act (2015), and Deprivation of Liberty Safeguards (DoLS) had been applied for appropriately. People were supported to make everyday choices within their capacity to do so. People had a choice of meals and received the support they needed to eat and drink. Staff we spoke with had a good understanding and knowledge of people`s individual care needs. Family members visited during the day with no restrictions.

The home was clean, tidy, comfortable and safe. Adaptations had been made to support people with mobility difficulties. People’s medicines were managed safely.

We observed that there were enough staff on duty and people did not have to wait for staff to attend to them. The rotas we looked at confirmed that these staffing levels were maintained by some use of agency staff.

Care records we looked at showed that people's care and support needs were assessed before they moved into the home. Plans were in place for meeting people’s needs and these were reviewed regularly.

The home employed two social activities organisers who facilitated social support for people both in the home and in the community.

We saw evidence of regular staff meetings and meetings for people who lived at the home. A series of quality monitoring audits was carried out.

We saw that people's needs were assessed and regularly reviewed. Care records were personalised, contained information about a person's individual needs and preferences and promoted the person's independence where possible.

Where people had limited mental capacity, care plans detailed how to communicate with people so they were able to be involved in decisions about their day to day care. Staff we spoke with were knowledgeable about a person's needs and understood the need to obtain consent prior to providing care and person's right to refuse consent.

We reviewed three staff records and saw evidence that staff were appropriately trained and supported to care for people safely and to an appropriate standard. Staff records demonstrated staff received training in safeguarding as part of the provider's mandatory training programme. Staff we spoke with had a basic understanding of safeguarding and the different types of abuse.

We saw the provider undertook a range of quality audits to check and monitor the quality of the service provided. We examined the provider's recent survey of people's views and opinions. The feedback received about the service was positive.

People we spoke with said:

'I am 200% better than when I came here.'

'There are all kinds of activities going on.'

'I'm now making my own meals and doing my own washing.'

'When I leave here I would like to come back as a volunteer and help other people.'

'I go to all the meetings.'

'The staff treat us with respect and we are involved in everything.'

'Everyone is friendly here.'

'My mum and my advocate visit me.'

'I was in a wheelchair when I came here, I'm much better now.'

There was a care plan for each person and the documentation was tidy and easy to follow.

Evergreen Lodge is a three storey building that has been adapted for use as a care home. Bedrooms, lounges and bathrooms were on the ground floor and the first floor, and the kitchen, laundry and other staff areas on the second floor. There was a detailed development plan for the building which was scheduled to start in February 2013.

There were enough qualified, skilled and experienced staff to meet people's needs. There was an effective complaints system complaints people made had been responded to appropriately.