Evergreen Lodge

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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.
The service was in breach of legal regulation 12 in relation to people’s safe care and treatment.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a lack of oversight of accidents and incidents due to the use of multiple recording systems and no analysis of Antecedent behaviour and consequences of distressed behaviours (ABC) which are utilised to help staff identify triggers, record what had happened and develop any learning. Information relating to accidents and incidents was not consistently or accurately recorded, which resulted in failures to identify and mitigate risks. Incidents whereby people required physical restraint were not always adequately recorded or signed off by management. This meant opportunities for learning were missed. Where learning was identified, it was not always clear how this was shared with the wider staff team.

There was limited evidence staff had shared important details effectively. For example, kitchen staff had been unaware of the dietary needs for some people including those who required a diabetic diet, which could have placed their health at risk. These issues demonstrated systems designed to support safe care had not always worked as expected. Referrals were made to relevant agencies in support of people’s needs; however, these were not always consistent. For example, when a person was receiving their ‘when required’ medication regularly, a request for a review from the GP was not always made.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. We identified and were concerned about the restrictions that were implemented and that these had where contributed to incidents that had required physical restraint. For example, people not being allowed to their bedrooms or for a cigarette outside of the care homes, scheduled smoking times.

For some people the relevant safeguards were not in place, this included the Mental Capacity Act (MCA) not being followed. The MCA is in place to promote and safeguard decisions within a legal framework.

Following on from the assessment CQC submitted safeguarding referrals to the Local Authority.

Staff spoken with were familiar with adult safeguarding policies and procedures.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We identified some risk assessments lacked clear, detailed guidance on how to minimise risk, when to escalate concerns, or what actions staff should take if a person’s needs changed. For people whose mobility abilities fluctuated, risk assessments did not provide clear guidance on which equipment should be used or when this should be implemented.

We observed unsafe moving and handling practices; this was reported to the registered manager and shared with the Local Authority safeguarding team.

The provider had not always identified, managed, and controlled risks within the care environment. Some areas of the service and items of equipment were not appropriately maintained which did not consistently support a safe environment for people. During the assessment, we saw damaged electrical plugs and sensor equipment that had been taped over, as well as stained ceilings. Some shower rooms were out of order, including one shower room that was not locked where water had pooled on the floor creating a hazard.

We identified water temperatures that presented a scalding risk to people; although audits undertaken identified the registered manager was aware of these high temperatures prior to the assessment, no actions had been taken to prevent or reduce the risk of harm to people. We discussed this with the registered manager who took immediate action to reduce the water temperature.

We also found that not all wardrobes were securely fixed to the wall, which could present a risk of significant injury to people. The registered manager told us they would take action to ensure all wardrobes were appropriately secured.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not work together well to provide safe care that met people’s individual needs. We observed poor moving and handling, the provider could not evidence all staff had been assessed as competent to support people with moving and handling safely. Staff had not received training in key areas relevant to people needs for example, learning disability, catheter care and person-centred care.

The dependency tool utilised to determine the number of staff required to support people safely did not accurately reflect people’s needs, resulting in insufficient staffing to support people safely. One staff member told us, “We are short staffed, but they [management] say we have enough staff.”

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We observed people’s bedding being dirty despite the bed being made, areas within the home were dirty, some of the communal chairs were stained. We identified dirty pressure cushions and sensor equipment. The fridge in one of the lounges had been removed, the reason provided to CQC was due to staff not looking after, it as a result we observed dairy products not refrigerated including milk and yoghurts. By not storing food correctly encourages bacterial growth increases the risk of contamination and places people at risk from foodborne illness.

The provider did not always make sure that the management of medicines and treatments were safe and met people’s needs, capacities and preferences. People were not always involved in planning how they were supported with medicines.

Medicines were not always safely stored; we found multiple topical creams unsecured in people’s bedrooms. Some creams had labels that were illegible meaning it was unclear who the cream was prescribed for and how it should be administered. Where people were prescribed medicines to be taken on an ‘as required’ basis, there was not always clear guidance on when a review by the GP should be requested. We identified one person who was receiving as required’ medication frequently, but no medication review had been sought and there was no guidance to indicate when this should occur. In addition, where medicines were prescribed with variable doses, there was not always sufficient guidance to support staff in deciding under what circumstances to administer 1 tablet or 2. This was discussed with the management team and CQC were advised all protocols for variable dose medicines were being reviewed.