Everdale Grange

Everdale Grange is a residential care home providing accommodation for people who require personal and nursing care for up to 68 people. The service provides support to older people, some of whom are living with dementia, people with a physical disability, mental health needs, sensory impairment and younger adults. At the time of our inspection there were 67 people using the service.

Everdale Grange is comprised of 2 separate buildings. In the first building are the Windsor and Tudor units. The Windsor and Tudor areas support people with long term nursing and personal care needs. The second building is the Sovereign unit, which focuses on short stay placements for people with rehabilitation potential. It has an onsite therapy team, who are funded separately by health partners.

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

People's safety was underpinned by the provider's policies and processes. Lessons were learnt and improvements made through the analysis and reporting of accidents, incidents, safeguarding concerns and investigations.

Potential risks related to people's care were assessed and included improvements to records to support a safe evacuation of people from the service in an emergency, and greater detail of the mitigation of risk linked to people’s care. Medicine systems were managed safely. People were supported by sufficient staff who had undergone a robust recruitment process and had undertaken training in topics to promote safety.

People lived in an environment which welcomed visitors and was well maintained and clean, with safe infection and prevention measures.

Records related to the assessment of people’s capacity to make informed decisions had improved. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People’s health and wellbeing needs were assessed, which included a tailored approach dependent upon the reason for a person’s admission to the service. The assessment process for people admitted for the purpose of rehabilitation, included assessments undertaken by occupational therapists and physio therapists, funded by health partners.

Staff had the knowledge and experience to meet people’s needs. People’s dietary needs were met, which included diets to suit their health, beliefs and culture. Staff liaised effectively with health care professionals to achieve good outcomes for people, confirmed by visiting professionals.

People and family members were positive about the kindness and compassion of staff, and of their commitment to promote people’s dignity. People were supported to practice their beliefs and celebrate their diversity. The cultural diversity of both people and staff was mixed, this provided for some people difficulties in making their needs understood, whilst for others it meant staff could speak with them in their first language.

The registered manager and management team were responsive throughout the inspection and implemented changes throughout the inspection and in response to our feedback. The provider had systems in place to monitor and improve the quality of the service provided, which was underpinned through consultation with people, their relatives and staff.

Staff received support, through training and supervision to promote good quality outcomes for people and attended regular meetings to share information and good practice.

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 requires improvement published 8 July 2022 and there were 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.

Why we inspected

When we last inspected Everdale Grange on 3 and 4 May 2022 breaches of legal requirements were found. This inspection was undertaken to check whether they were now meeting the legal requirements.

We undertook a focused inspection to review the key questions of safe, effective, caring and well-led only. For the key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Everdale Grange is a care home. It is registered to support up to 68 people. At the time of our inspection there were 62 people using the service.

The service is split into two separate buildings. In the first building are the ‘Windsor and Tudor Wards’. The Windsor and Tudor areas supported people with longer term complex nursing and mental health needs.

In the second building was the ‘Sovereign unit’. This Sovereign unit was focused on shorter stay placements for people with reablement and rehabilitation potential. It had an onsite therapy team, who were funded separately by the local clinical commissioning group.

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

Risks at the service were not always managed safely. There was a lack of guidance on how to support people with complex needs in the event of an emergency evacuation. Medicines were mostly safely managed. There was some missing guidance for ‘as needed’ medicines. However, this was put in place during the inspection. People were not always provided with suitable support for their swallowing needs. We were not assured that people were always protected from the spread of infection at the service. People felt safe at the service. There were enough staff and these staff were suitably trained. Incidents (like falls), were analysed to reduce the future risk where possible.

The service used nationally-recognised tools to provide effective care. People were supported to eat and drink enough to prevent malnutrition and dehydration. External health and social care professionals were involved with the service where needed. People were provided with a variety of activities at the service. People appeared to engage positively with these activities to prevent social isolation.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests. The systems in the service, did not support this practice. We saw written thankyou cards from relatives about the end of life care for people who had passed away at the service. A visiting professional also told us that end of life care was good quality.

Some staff showed less caring interactions than others. However, we received positive feedback from relatives about the caring nature of the staff team.

Where people or relatives had complaints about the care provided, these complaints were recorded and responded to appropriately. Where needed, care had been improved as a result. Relatives fed-back positively about the activities provided to people. People’s diverse needs were understood and met.

Governance systems were not always effective at ensuring high quality care across the service. However, the management team were responsive to feedback and had begun to make changes while we were inspecting. We will assess the impact of this at our next inspection.

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 5 February 2020).

Why we inspected

The local authority had received some safeguarding concerns about the service. They were still in the process of investigating these individual allegations. We made the decision to complete an unannounced comprehensive inspection of the service to assess the overall safety of care provided.

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.

We have found evidence that the provider needs to make some improvements. You can see what action we have asked the provider to take at the end of this full report. The provider was responsive to our concerns and took action during the inspection process to improve the safety of the service.

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

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care, consent and governance. Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

Safe arrangements were in place for visitors to the service including professionals and others. This included rapid LFD testing, hand washing, PPE stations, and dedicated areas for visiting.

Visiting professionals were asked to provide evidence of their vaccination status against COVID-19 prior to entering the home. All staff were required to be vaccinated, and a record of this was kept by management.

A programme of testing for COVID-19 was in place for all staff and people.

Isolation, cohorting and zoning plans were used to manage the spread of infection. This meant people self-isolated in their rooms when necessary.

Stocks of PPE (personal protective equipment) were readily accessible to staff and visitors, and regular checks were made to ensure they were being used.

Policies, procedures, risk assessments and guidance relating to COVID-19 were up to date, which supported staff to keep them and others safe.

Management conducted regular checks and audits to ensure the service was kept clean and tidy.

Staff were trained in infection prevention and control procedures, including the procedure for safely putting on and taking off PPE (donning and doffing).

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

We found the following examples of good practice.

¿ The provider had identified a specific area within the home to ensure effective use of cohorting and zoning. That meant that people had rooms and facilities in a certain area of the home and were cared for by a dedicated staff team, which reduced the potential for the infection to spread. Staff were appointed to work in designated areas which further reduced the potential for transfer of infections.

¿ There was a designated central entry system into the service. Everyone was temperature tested and completed hand disinfection before entry. Anyone being admitted from hospital who were potentially Covid positive were admitted directly to the designated area.

¿ The provider ensured there was a plentiful supply of personal protective equipment (PPE) including face masks and aprons and we saw staff used this appropriately. Staff were encouraged to change their PPE regularly. Used PPE was disposed of in special foot operated pedal bins situated throughout the home which ensured the potential for transfer of infection was reduced.

¿ Staff were aware of the process to encourage people to wash their hands frequently throughout the day.

¿ The provider participated in regular Covid-19 testing of people living in the service and staff. That ensured action could be taken swiftly to reduce the potential spread of infection if a positive test was returned.

¿ Areas were thoroughly cleaned and disinfected with cleaning products approved to reduce the potential transfer of infection.

¿ Risk assessments had been completed to protect people and any staff who may be at higher risk should they contract Covid-19 and measures were in place to support them. Staff were supported by the option of accessing wellbeing support. The provider had appointed a member of staff to coordinate the wellbeing of all the people in the homes, their relatives and staff in all the company locations.

¿ Staff worked in set teams with few changes of staff from shift to shift. This lessened the potential of cross infection from team to team.

Further information is in the detailed findings below.

Everdale Grange is a care home providing personal and nursing care to up to 67 older people. At the time of the inspection, 66 people were using the service.

Everdale Grange accommodates people across three separate areas within the building, one of the areas specialises in providing short term reablement care. The other areas specialise in caring for people living with dementia, physical disabilities, nursing care and palliative care.

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

People told us they received safe care. Staff we spoke with understood safeguarding procedures and were trained in this area.

Risk assessments were in place to manage risks within people’s lives, and staff understood how to follow them and provide safe care to people.

Staff recruitment procedures ensured that appropriate pre-employment checks were carried out.

Medicines were stored and administered safely. Some improvements were required to ensure the recording of all topical medicines was clear and complete.

Staffing support matched the level of assessed needs within the service during our inspection, and people and relatives we spoke with said that staffing levels were sufficient.

The home was clean, tidy and well maintained, and people confirmed that staff followed infection control and food hygiene procedures effectively.

The management staff we spoke with were open and honest, and worked in partnership with outside agencies to improve people’s support when required. Audits of the service were detailed, and any issues found were addressed promptly. The service had a registered manager in place, and staff felt well supported by them.

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 12 April 2019).

Why we inspected

We received several concerns in relation to the safe care and treatment of people, infection control standards, staffing levels, management of falls, and medication. 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.

The overall rating for the service has not changed. This is based on the findings at this inspection.

We found no evidence during this inspection that people were at risk of harm from these concerns. 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 Everdale Grange 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.

People’s experience of using this service:

¿ People told us they felt safe at the service and supported by staff who were trained in safeguarding procedures. The provider had effective safeguarding systems and policies in place.

¿ Potential risks to people’s health, safety and welfare were assessed, managed and monitored on an ongoing basis.

¿ People were supported to take their medicines safely and their health care needs were met appropriately.

¿ Staff were recruited safely and there were enough staff to meet people’s needs.

¿ People were supported by staff who had undertaken training and were knowledgeable about people’s needs and had their competency assessed.

¿ People lived within a well-maintained environment, which took account of people’s needs and provided signage to help them navigate around the service.

¿ People’s rights and choices were promoted on an ongoing basis. We saw evidence of mental capacity assessments being carried out as required. People’s family and relevant health care professionals were consulted as part of best interest decisions.

¿ People were supported to have maximum choice and control of their lives and caregivers supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

¿ People spoke positively about the meals provided and they were supported to eat and drink as required.

¿ People’s equality and diversity was respected, and their privacy and dignity maintained. Positive care relationships had been developed between people and the staff who cared for them.

¿ People’s cultural and religious needs were identified and supported.

¿ People and relatives were fully involved in all aspects of care planning where appropriate.

¿There were effective systems in place to support people when they reached the end of their lives to ensure their wishes and needs were planned for.

¿ People’s care was personalised to their individual needs and staff worked flexible to accommodate this.

¿ People and where appropriate their relatives were encouraged to contribute in the review of their care regularly.

¿ The management and staff team were creative, committed and promoted supporting people with living with dementia. We saw national best practice guidance was used effectively which had had positive impact on the lives of people living with dementia. There were a variety of meaningful activities arranged that were of interest to people. Care provided was personalised in all aspects and monitored. This was essential for people receiving rehabilitation care and support.

¿ The service encouraged people to maintain links with family, friends and the local community. Inter-generation activities and links with schools was promoted and had benefited the lives of people living with dementia.

¿ An open and transparent culture enabled people and staff to speak up if they wished to. There was a system in place to respond to complaints and advocacy support was available.

¿ People, their relatives and staff had opportunities to give feedback and influence service development.

¿ There were robust quality monitoring systems and processes in place which were supported by policies. Action was taken where areas for improvement had been found and any lessons learnt from incidents were shared with the staff.

¿ The provider, registered managers and staff team worked well with professionals and external organisations and they effectively used good practice guidance to promote people’s quality of life.

Rating at last inspection: This is the first comprehensive inspection carried out at Everdale Grange since they registered on 23 March 2018.

Why we inspected: This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

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