Evelyn House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. Under this key question, we found a breach of regulation 12, in relation to safe care and treatment, over concerns around assessing risks to people’s health care and safety and medicines management.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety. Senior staff and the registered manager listened to concerns about safety and investigated safety events. Lessons were learnt to continually identify and embed good practice.

Staff discussed safety matters with people living at the service, while ensuring their views were heard.

Staff knew how to report accidents and incidents. They held debrief sessions in which accidents, incidents and other concerns were discussed and learning was shared. Staff also used ABC charts (Antecedent Behaviour Consequence chart - a tool used to observe and analyse behaviours) to help them understand the reasons behind certain behaviours or actions displayed by people and find ways to better support people. These practices showed a commitment from staff to continuously improve the service while promoting safety for people.

The service collaborated with people and health and social care partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

Managers assessed people’s needs prior to them being admitted to the service. This enabled them to identify the care and support needs people would require and make sure the necessary arrangements were in place to facilitate a smooth transition.

Following the admission of a person to the service, the registered manager reviewed any identified risks and implemented control measures. This promoted the safety of the people already living at the service and any newly admitted person.

The service operated systems to protect people from abuse, neglect and discrimination. Staff understood safeguarding requirements and knew how and when to report concerns.

If safeguarding concerns were suspected, a staff member told us they would “report immediately to their manager, take staff off shift [if needed], contact CQC and the local authority.”

People told us they felt safe at the service and were comfortable to raise concerns. A relative told us, “Person is safe at the service.” The registered manager told us there had been no safeguarding concern raised in the past 6 months.

For people whose freedom was restricted, the appropriate legal authorisations were sought when needed.

While the service assessed risks to people’s health, care and safety, clear guidance on risk reduction measures was not always available. Additionally, a number of identified risks to people had not been fully assessed. This meant people were at risk of not receiving safe care and support, which placed them at risk of harm.

One person had a specific health condition and their records showed they experienced symptoms relating to this condition in March 2025, which required hospital admission. However, their risk assessments did not include guidance on how to safely manage this health condition. The same person had 2 episodes of ill health related to a lack of fluid intake within a period of 2 weeks. While staff encouraged fluid intake and recorded the amount of fluid the person consumed, the total recommended daily amount of fluid was not specified in their care plan / risk assessments to help staff ensure the person consumed enough fluids to prevent dehydration. No dehydration risk assessment was in place. The service implemented the appropriate risk assessments following the inspection. People using emollient creams did not have appropriate risk assessments in place. Emollient creams, when dried onto fabric, can significantly increase the risk of fire.

Despite staff developing positive working relationships with people, clear guidance on how to support people safely in relation to some of their identified risks was not always documented. For example, a section in one person’s care plan stated, “Monitor for potential behavioural triggers and respond with flexible, person-centred support.” The care plan did not elaborate further on the triggers staff to look for and did not specify what the flexible and person-centred support entailed.

The service conducted regular fire drills to increase staff’s preparedness in the event of a fire. However, fire drill records did not include key information, such as details of the people and staff who took part in the drill, evacuation time and whether people cooperated, to ensure the exercise achieved its intended purpose. The registered manager provided the key information about the fire drills following the inspection.

In contrast, some sections in people’s care plans and risk assessments contained clear and detailed information for staff on how to support people safely. However, the above examples demonstrated shortfalls in the service’s process of assessing risks to people. This meant people were exposed to risks of receiving potentially unsafe care and support.

People lived and received care and support in a safe environment. Facilities were maintained appropriately and consistently supported staff to deliver safe and effective care.

We found multiple safety concerns in a person’s ensuite bathroom, including cracked floor tiles and an inadequately sealed toilet base. However, staff had already identified and reported these issues through recent internal health and safety checks. The provider addressed them shortly after the inspection visit.

Staff carried out regular health and safety checks on the environment, including checks on maintenance issues, fire safety and equipment. The service also arranged for inspections by external contractors in relation to gas safety, electrical installation and building fire risk assessment. Staff knew how to report maintenance issues which were monitored by the management team.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff received training in a range of areas in line with their job roles. This ensured staff had the right skills and knowledge to support people safely and effectively.

The service conducted the necessary checks to ensure staff were recruited safely. However, the service had not received work references for 1 staff member despite having sent multiple requests to their former employer. The service had proceeded to recruit the staff member on the basis of their DBS check but without seeking alternative assurances around the staff member’s conduct in their previous employment. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff received support through regular supervision and appraisal. Newly recruited staff were enrolled on an induction programme during which they received appropriate guidance and training. Managers assessed staff’s competency in several areas, including personal care, infection control and moving and handling. This ensured staff’s practices remained safe and in line with best practice.

The service assessed and managed the risk of infections.

Staff wore personal protective equipment (PPE) as required. PPE stations were fully stocked. Staff also followed safe food handling procedures to maintain good food hygiene.

Overall, premises, including communal lounge/dining areas, people’s rooms, the kitchen and bathrooms, looked clean and hygienic.

Managers and senior staff carried out comprehensive infection control checks on the premises.

There were systems and processes in place to make sure staff managed and administered medicines safely while respecting people’s personal preferences. However, we found concerns around some aspects of medicines management.

Some people were prescribed ‘when required’ (PRN) medicines, such as painkillers and medicines for anxiety. However, PRN protocols containing guidance on when to administer these medicines were not in place on the day of the inspection visit. The registered manager provided PRN protocols following the inspection visit. Staff did not record the times of administration of PRN medicines, reasons for administration and outcomes. Medicines in liquid-form that are stored in their original bottles could have a shortened shelf life once they are opened. However, staff did not record the opening dates for these medicines to make sure they were used within their respective shelf lives. We found an expired medicine box that was stored in the medicines cabinet together with people’s current medicines. These issues indicated people were at risk of not receiving their medicines safely and as prescribed.

We raised these issues with the managers who had begun taking actions to address them after our visit. Staff completed medicines administration records appropriately for people’s regular medicines. People’s care plans contained clear information on their medicines. Managers assessed staff practices regularly to make sure they remained competent to administer medicines. We observed a staff member administering a person’s medicines safely and respectfully.