Evelyn House

Ratings

• Overall

  Requires improvement

• Safe

  Requires improvement

• Effective

  Good

• Caring

  Good

• Responsive

  Good

• Well-led

  Requires improvement

Our view of the service

Date of Assessment: 13 May 2025 (site visit). The service is a residential service providing care and support mainly to people living with mental health conditions. At the time of the assessment, 6 people were being supported at the service.

Safety was not always managed adequately. We found concerns in how the service assessed risks to people and management of medicines. While we found no evidence of people coming to harm, these concerns indicated people were at risk of harm. The service carried out recruitment checks to make sure only suitable staff were employed. However, recruitment records for 1 staff member did not show complete adherence to safe recruitment requirements. Staff received training in a range of areas to remain knowledgeable in their roles, but there were gaps in training monitoring systems. People’s eating and drinking needs were not consistently assessed or documented. Information on people’s needs were documented in their care plans. However, the information presented was not always complete or sufficiently specific to ensure guidance for staff was clear and robust. We found inconsistencies and shortfalls in the governance of the service, including the effectiveness of quality assurance systems. These concerns amounted to a breach of regulation in relation to safe care and treatment, and a repeated breach of regulation regarding good governance. We have asked the provider for an action plan in response to the concerns found at this assessment. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

Equally, we found a number of examples of good care and good practice. Regular meetings for people and staff were now taking place. Staff were aware of their safeguarding duties. Accidents and incidents were recorded and reviewed appropriately. Staff adhered to infection control practices to protect people from infections. People had enough to eat and drink to stay healthy. Staff monitored people’s health and wellbeing, and escalated concerns appropriately to support healthy living. The provider supported staff wellbeing. Leaders were visible and supportive, and helped staff develop in their roles. Staff felt supported to give feedback and were treated fairly. Staff worked in partnership with other organisations to provide effective care to people. The provider was no longer in breach of regulation regarding staffing.

People's experience of this service

People’s experience of the care and support they received was overall positive. They felt safe living at the service and were supported to understand their rights. The service was accessible to people and staff provided them with fair and equal care. People engaged in a range of indoor and outdoor activities of their choice. This protected people from social isolation and helped them stay active. There were means for people to share their views and express any concerns. People were supported by a kind, caring and respectful staff team. However, the physical layout of the service did not ensure people’s privacy and dignity were fully promoted. The provider told us they had made plans to address this issue.