Evelyn House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. Under this key question, we found a repeated breach of regulation 17, in relation to good governance, over concerns around quality assurance systems, risk management and record keeping.

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.

People received care and support from a staff team that was trained, supported by their leaders and guided by appropriate processes and policies. This created a positive culture within the service and a safe environment for people and staff.

Leaders supported staff by setting clear expectations and encouraging regular discussions around best practice. Recent staff meeting minutes showed conversations were held on different topics, including people’s wellbeing, health and safety, documentation and staff training needs. This indicated staff and leaders were constantly looking for ways to improve the service for people and create a positive working environment for staff.

Staff told us they enjoyed working at the service. Their comments included, “I love coming to work and working here; It's rewarding to know I make such a difference to someone's life” and “We don’t have issues with each other, we talk and support each other.”

Leaders had the skills, knowledge, experience and credibility to lead effectively. They worked as a team and addressed poor practice that could affect the quality of people’s care.

Although the registered manager was not permanently based at the service, they visited regularly and made sure they were available when needed. The service was also overseen by a care manager who worked closely with the registered manager and the staff team at Evelyn House. A staff member told us they had the right support from the managers. They also said, “[Manager] is amazing, you can call them day and night, even if they are on holiday.”

Leaders used succession planning to develop staff into senior roles. This approach empowered staff, ensured business continuity and minimised disruptions to people’s care.

However, the managers did not fully understand their responsibilities towards the requirements of certain parts of the regulations in health and social care. This is reported further under the governance, management and sustainability quality statement.

The service fostered a culture where staff felt they could speak up and their voice would be heard. Leaders encouraged staff to escalate concerns promptly and this was evidenced in staff meeting minutes.

Staff understood their responsibility to report concerns and the different channels to do so. They told us the managers were approachable and supportive. Staff felt comfortable to engage with the managers and had access to different electronic systems to share information.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us leaders were helpful and would try to accommodate their needs. This promoted their wellbeing and helped them perform to the best of their abilities.

Managers recognised staff’s contribution and performance via an incentive programme. Staff spoke to us about the opportunities they had to develop their skills and progress in their career. A staff member told us, “I’m happy working here, no complaints.”

Governance and accountability systems were not always robust and effective. Managers did not fully understand their regulatory responsibilities. Risk management systems did not operate efficiently.

The service undertook a series of audits to assess and improve the quality and safety of the service. However, existing quality assurance systems had not identified the issues we found in this assessment, including issues around assessing risks to people, medicines management and care planning. This indicated quality assurance systems were not always effective.

Systems to assess, monitor and reduce risks to people’s health care and safety were not robust. Risks or hazards were not always identified and/or assessed. Where risks had been identified, risk assessments did not always contain clear guidance to ensure staff, including newly recruited and temporary staff, remained well-informed on the safest ways to support people.

The service did not always ensure records related to people’s care and staffing records were accurately maintained. For example, guidance on PRN (‘when needed’) medicines was not in place for any person on the day of the inspection visit. As reported under a number of quality statements, information in people’s care plans was not always complete or accurate. There were discrepancies in staff training records. The provider did not always ensure certain care or management records were in place or accessible for review at the time of the assessment. The registered manager submitted a number of records after we had provided feedback on the assessment despite having had the opportunity to do so during the assessment.

At the time of this assessment, the provider had not adhered to the terms of their registration regarding the number of people they could support and accommodate at Evelyn House. The provider had also failed to display their rating from the last inspection on their website and at the location. The rating was displayed subsequently.

However, there were other ways in which the service demonstrated good governance. A number of their audits were comprehensive and used effectively to identify concerns and make improvements. Organisational policies and procedures were clear and up to date. The registered manager showed much interest in using data and technology, and had implemented several electronic systems to improve governance and care delivery.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and worked together with partners to improve the quality of care for people. We found clear records of interactions between the service and other agencies.

While the provider invested in technological means to improve the service, there was a lack of focus on learning from past issues and making sustained improvements.

Our assessment revealed several recurring concerns which were identified at the last inspection, including concerns around assessing risks and medicines management. This showed, despite the service having taken steps to make changes, sufficient improvements had not been made or sustained in some areas of the service.

The service captured feedback from people, relatives, staff and visitors through various methods. The feedback was used to monitor and improve the quality of service. However, 2 relatives told us they were not asked for feedback except through a brief ‘rate your experience’ survey when exiting the service, which one of the relatives did not find particularly useful. We fed this back to the managers who explained feedback questionnaires were usually sent to all relatives but this year’s survey was yet to go out.

Nonetheless, we found improvements in several areas, including the introduction of regular team meetings to share information effectively, increased staff awareness of the principles of the Mental Capacity Act and effective coordination between the care manager and the registered manager. The provider had a service improvement plan in place which showed the areas identified for improvement and the progress being made.