We carried out a review of the data available to us about Evington Grange on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Evington Grange, you can give feedback on this service.
People’s experience of using this service and what we found
At our last inspection the provider had failed to keep people safe and comprehensively monitor the quality of the service. The provider had not undertaken regular fire checks and lacked a comprehensive medicine management system. There were insufficient audits of medicine. At this inspection we found the provider had made improvements. Systems and processes were in place to keep people safe. There had been an improvement in assessing and monitoring the quality of care provided, though this had not always shown what action had been taken to identified issues.
People felt safe with staff from the service. Staff understood how to protect people from the risk of harm and understood potential signs of abuse. Care plans provided guidance for staff to follow, which staff had read and understood. Risk assessments reduced risk for people. Staff went through a recruitment process so that the provider only employed suitable staff, though this needed to be made more robust.
Systems were in place to monitor the quality of care and support people experienced through quality assurance systems and processes to improve the service though actions identified were not always evidenced as being carried out.
People received their medicines as prescribed and they were protected from the risk of infections through staff working practices. There were enough staff to meet people’s needs. Staff undertook induction and specialist training which provided knowledge and skills to do their job well and effectively meet people’s needs.
People were provided with care and support that ensured they had good nutrition and hydration. They had access to healthcare that maintained their health and wellbeing. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible.
Staff knew people well. People had developed positive relationships with staff which helped to ensure good communication and support. Staff respected people’s privacy and dignity. They supported people to be independent.
People were involved and consulted when deciding how support was provided. Staff knew and understood the needs of the people using the service and care was provided based on their assessed needs. Staff were responsive to changes in people's needs to ensure they received help to maintain their health and well-being.
People knew how to raise any concerns or make a complaint. The provider had a system in place to respond to complaints to put things right. The complaints policy provided information about how these would be managed and responded to.
People and staff spoke positively about the management and leadership of the service. They said staff were very friendly and caring, and they had built good relationships with them.
The service worked in partnership with external agencies to ensure people achieved good outcomes from their care and support.
Rating at last inspection:
The last inspection on 28 September 2018 rated the service as requires improvement.
Why we inspected:
This was a planned inspection based on the last rating.
Follow up:
We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
This was the first inspection of the service since they were registered on 7 August 2017. At this inspection we found evidence to support the rating of Requires Inspection.
There was a registered manager was in post. 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 2008 and associated Regulations about how the service is run.
Evington Grange is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Evington Grange accommodates up to 6 people in one adapted building.
The inspection was a first rating inspection.
The provider carried out some quality monitoring checks in the home supported by the registered manager and home’s staff. However, there were shortfalls in the training matrix, fire and evacuation system, the recruitment application form, statement of purpose and medicines system and competency of staff when administering medicines were also out of date.
The provider had a clear management structure within the home, which meant that the staff were aware who to contact out of hours if an emergency arose, or an equipment repair was necessary. Staff had access to the maintenance diary to manage any emergency repairs. The provider had developed opportunities for people to express their views about the service, however, not many of the current people living in the home had the chance to participate in the latest questionnaire. These included the views and suggestions from people who used the service.
We found that applications had been made to the local authority to legally deprive people of their liberty. The registered manager and care staff had been trained in the Mental Capacity Act (MCA) 2005. They were also aware where best interests meetings would be planned to ensure people’s treatment was in line with the MCA and Deprivation of Liberty Safeguards. People or where appropriate their representatives were asked for their written consent to care following their admission to the home.
Following their recruitment staff received on-going support and training for their job role. Staff were able to explain how they kept people safe from abuse and were aware of whistleblowing and what external assistance there was to follow up and report suspected abuse. Staff were subject to a thorough recruitment procedure that ensured staff were qualified and suitable to work at the home.
People were supported to continue with their chosen dietary and cultural needs. Staff supported people to undertake a range of activities that were tailored to people’s interests and needs. Staff had access to information and through this had developed a good understanding of people’s care and support needs. Care and support plans were updated to include changes to peoples care and treatment and people were involved in the review of their care and support plan. People were offered and attended routine health checks, with health professionals both in the home and externally.
People were able to maintain contact with family and friends and visitors were welcome without undue restrictions. We observed staff interacted positively with people throughout the inspection, people were offered choices and their decisions were respected.