Evelyn May House

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.

We found the following examples of good practice.

Staff are provided with easy read posters of what Personal Protective Equipment (PPE) staff should wear when supporting COVID-19 positive residents. The laminated posters are attached to the residents’ doors.

The registered manager undertakes competency assessments of staff “donning and doffing” PPE. This ensures staff are correctly following national guidelines when supporting residents.

Where residents are COVID19 positive, boxes of PPE are kept outside the resident’s bedrooms to ensure staff appropriately wear the correct equipment.

Further information is in the detailed findings below.

Evelyn May House is a care home providing personal care and accommodation for up to 59 people. On the day of inspection, 58 people were using the service. The service does not provide nursing care.

People’s experience of using this service:

People's experience of the service in the main was very positive. This was summed up by one person who told us, "Here is wonderful. I’ve been here two years now I think, I’m very happy, the staff are fantastic they always help me; I was a bit upset this morning but the nurse came in and helped me, she was fantastic; I like shopping in the town and sometimes we're taken out.” Areas identified by people and relatives that required improvement were more meaningful engagement between staff and people, more stimulation and support to access more activities within and outside of the service.

We made a recommendation about activities.

People said they felt safe at the service. Risks to people were assessed and staff knew what to do to keep people safe. People's medicines were safely managed. Good infection control practices were in place. There was sufficient staff who had been safely recruited to keep people safe. Staff received training in safeguarding and knew the signs to look for that people might be being abused and knew how to report any concerns. Staff knowledge around whistleblowing needed strengthening.

We made a recommendation for staff training on whistle-blowing.

Staff enjoyed working at the service and felt well supported. There were a range of mechanisms in place to monitor and support staff to ensure they had the skills and knowledge to provide effective care and support. People were supported to have enough to eat and drink which met their needs and preferences. People’s healthcare needs were met in a timely way. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff were kind and caring and knew people well. People were included in decisions around their care and support. People's privacy and dignity was respected. Independence was supported and encouraged. The service helped people maintain important relationships and visitors were made welcome at the service.

There were systems in place to respond to concerns and complaint. Staff had received training in end of life care and thoughtful consideration had been given on how to compassionately support people at the end of their life. Information could be provided to people in a range of formats if requested. However, more thought could be given on how to present information to make it easier for people to access and understand.

We made a recommendation about making information accessible.

The service was well-led by a visible and approachable registered manager who was well thought of by the staff team. The service engaged with people and staff to include them in how the service was run. Feedback was invited and acted upon. Quality assurance audits were in place to monitor the safety and quality of the service and drive improvement. The provider had good oversight of the service.

Rating at last inspection: Good. (Last report published March 2017).

Why we inspected: This was a planned inspection based on the previous rating.

Follow up: We will continue to monitor the service.

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

At the last inspection, the service was rated good and at this inspection we found the service remains good.

People were protected from the risk of harm and received a safe service. There were enough staff who had been safely recruited to help keep people safe and meet their needs and preferences. The service managed medication well and people received their medication as prescribed.

People were cared for by supported, experienced and well trained staff. They had the support they needed to have as much choice and control over their lives in the least restrictive way possible. People received sufficient food and drink to meet their needs and preferences and their healthcare needs were met.

Staff were kind, caring and compassionate in their approach and knew the people they cared for well. People were encouraged to remain as independent as possible and staff supported them when necessary. Staff treated people with dignity and respect and maintained their privacy at all times.

People and their relatives were fully involved in the assessment and care planning process. Care plans had been regularly reviewed to reflect people’s changing needs. There was a range of activities available to suit individual’s interests. Complaints had been dealt with appropriately in a timely manner.

People were positive about the quality of the service. The registered manager and staff were committed to providing people with good quality person centred care that met their individual needs and preferences. There were good systems in place to monitor the quality of the service and to drive improvements. The service met all relevant fundamental standards.

Further information is in the detailed findings below.

Those people who were unable to communicate were observed during the day and their body language and facial expressions noted. They appeared relaxed with staff and no concerns were seen or raised. Care staff were observed speaking with people with dignity and respect and involving them in their care. Staff members were viewed helping people to make choices on how they wanted their care provided.

People told us they knew how to raise any concerns. They added they found the manager approachable and could take any concerns they may have to them. Staff spoken with also added that they felt that they could raise any concerns they may have with the manager. One staff member reported that, 'There is a good team here, we all work well together.'

Feedback from a health care professional spoken with stated that communication at the home was good. They said that the staff would always refer any concerns they had if there was a problem. They added 'The staff team and manager listen and work well together ' I have no concerns.'

The environment was well maintained and met people's needs. The manager was in the process of developing the environment on the second floor and people's bedrooms to help make it a more stimulating place for those people who are living with some form of dementia.

During our visit at no time were people seen waiting for staff to support them. Some issues were raised with staffing levels at meal times due to the number of people who needed assistance, but the manager took appropriate action to address this issue.

People we spoke with were complimentary about the care and their comments have been recorded throughout the report. Others who were unable to verbally communicate were observed with staff and they appeared relaxed in their company. Comments included, 'In this time where there have been so many bad reports on care homes; it is a real pleasure to find one so caring. I would just like to say a big thank you to you all for making 'X' feel happy and secure,' 'I would like to thank you for looking after 'X', you all do a wonderful job and make life easier for families with loved ones in your care,' and 'I would like to compliment the home on the excellent standards of care. The staff are always very friendly and helpful. They also demonstrate excellent knowledge and skills, in relation to their clients.'

People told us they knew how to raise any concerns. Relatives spoken with stated that they found the manager to be approachable and felt they could take any concerns they may have to her.