Background to this inspection
Updated
22 November 2018
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
The inspection started on the 25 September and ended on 1 October 2018. The first day of inspection was unannounced, and the second day was announced.
The membership of the inspection team included one inspector and an expert-by-experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. Their specific area of expertise was in dementia care. We also used a specialist nurse advisor, and their area of expertise was in clinical governance.
Before the inspection, we reviewed information the provider sent us in the provider information return (PIR). This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. We also reviewed other information that we held about the service such as statutory notifications that had been sent to us by the provider. These detail events which happened at the service, which providers are required to tell us about. We also contacted commissioners for any information they held on the service.
We made general observations of people using the service being supported by staff. We spoke with eight people using the service, three visiting relatives, the activity person, three care staff, two qualified nurses, the business manager and the two registered managers. We reviewed the care plans and associated care records for four people using the service. We looked at the recruitment files of three staff, and other documents relating to staff training, supervision and support and the management oversight of the service.
Updated
22 November 2018
This inspection took place over two days, on 25 September and 1 October 2018. The visit on the 25 September was unannounced and the visit on the 1 October 2018 was announced. This was the first inspection of the service since the provider changed registration with the Commission in September 2017.
Evington Home - Pilgrims' Friend Society 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.
The service can accommodate up to 30 people in one adapted building. At the time of the inspection the service was providing care for 26 people. The Christian faith was at the heart of the service, and fundamental to meeting people’s spiritual needs, as this was one of the reasons why people chose to live at the home.
Two registered managers were employed by the provider to manage the service. 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.
People felt safe and protected from harm and able to raise any concerns regarding their safety. Staff understood how to keep people safe and how to report any concerns regarding their safety or welfare. The service safely supported people with the administration of medicines. Safe recruitment procedures were carried out and there was sufficient staff available to meet the current needs of the people using the service.
Risk assessments addressed the potential risks present for each person and monitoring records were used to manage the risks. These were also used to recognise when specialist advice from other healthcare professionals needed to be sought in response to changing needs.
Systems were in place to question accidents and incidents to learn from them and mitigate the risk of any repeat incidents. The registered managers and the provider analysed these to address areas identified for further improvement.
The premises were kept clean and hygienic so that people were protected from infections that could affect both staff and people using services. Regular checks to the safety of the environmental took place and people had personal emergency evacuation plans (PEEP’s) in place, in the event of a major emergency requiring evacuation of the premises.
People were provided with nutritious meals and people identified at risk of losing weight, or those with swallowing difficulties were referred to health professionals for specialist care and advice.
People’s needs were fully assessed before moving into the service, and people and relatives confirmed they were involved in the assessments. The service worked and communicated with other healthcare professionals, so that people received effective care and support when moving between different care services.
The principles of the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) safeguards were met. The provider had a system to track DoLS applications and authorisations to identify when renewals were required and to follow up on any outstanding applications.
People and relatives confirmed the staff were kind, compassionate, and friendly. People were encouraged to express their views and make choices. The staff knew the people who used the service well and had built trusting relationships. There was a policy on confidentiality and information about people was shared only on a need to know basis. People’s confidential information was stored appropriately.
People spoke positively about the activities provided at the service. People’s physical, emotional and spiritual, needs were met. People were supported at the end of their life to have a comfortable, dignified and pain-free death and where possible people were able to remain at the home and not be admitted to hospital.
The service looked at ways to make sure people had access to the information they needed in a way they could understand it; to comply with the Accessible Information Standards. The Accessible Information Standards is a framework put in place from August 2016 making it a legal requirement for all providers to ensure people with a disability or sensory loss can access and understand information they are given. People had information on how to complain or raise any concerns about their experience of using the service. Complaints that had been received at the service were responded to appropriately.
Effective quality monitoring systems looked at all aspects of the service. A variety of internal audits were used to continuously drive up improvement. The registered managers notified CQC of events as required by law under the registration regulations.