The Evergreens Lodge

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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents and near misses were recorded and reviewed by the manager to ensure actions were implemented. Learning from incidents was shared with all staff to ensure they understood changes in the way they needed to support people. Examples included changes in equipment used for people at high risk of falls and changes in processes to ensure people did not leave the building without support from staff.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Relatives told us systems worked well when people first moved to the home, with good communication. People’s health conditions were documented, and they were supported to access services from a range of health and social care professionals.

On the day of our visit the provider was supporting a person to move to another service which was better placed to meet their needs. The move had been carefully planned with input from specialist professionals, which minimised distress to the person. Social care professionals were positive about the support people received. Comments included, “The Evergreens Lodge appear to have systems in place to ensure the safety and security of their residents. I would say my client receives good continuity of care.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Relatives said they felt people were safe living at the service. Staff demonstrated a good understanding of their safeguarding responsibilities and said they had completed safeguarding training and had regular discussions about safeguarding issues. Staff were confident the manager would take appropriate action if they reported any safeguarding concerns. Staff were aware how to raise any safeguarding concerns outside of the provider organisation if they needed to.

Where appropriate the provider had applied to the local authority for Deprivation of Liberty Safeguards (DoLS) authorisations. The manager had a record of all DoLS applications that had been made, including details of any conditions to the authorisations.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and relatives told us they felt safe. Risks to people’s health, safety and welfare had been assessed and plans developed to manage those risks. People had emotional support plans where needed, setting out details of how to support people during periods of distress. Staff demonstrated a good understanding of the risks people faced and how to support them safely. Staff told us risk management plans were regularly reviewed and updated as people’s needs changed. Staff had access to updated plans through the electronic care planning system and were notified of any changes.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

At the last inspection we identified shortfalls in the way the property was maintained to ensure a safe environment. At this inspection this had improved.

People told us the home was well maintained. The provider assessed the service for risks and took action to ensure people, staff and visitors remained safe. Equipment, such as fire systems, window restrictors, gas systems and hoists had been regularly serviced and tested to ensure they were safe. Staff told us action was taken quickly when repairs were needed.

The provider had a legionella risk assessment, and an external company regularly tested the water systems to ensure they were safe. However, recent staff absence had led to some flushing of unused taps not being completed when they were due. The manager took immediate action to address the shortfall and implement new systems to ensure these tests were not reliant on a single member of staff.

The provider 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.

At the last inspection we identified shortfalls in the arrangements for staff training. At this inspection this had improved, with staff now receiving training relevant to their role. The manager had effective systems to track the training staff had completed and when refresher training was due.

People and relatives felt there were enough staff available and said staff generally responded quickly when they requested assistance. People said staff had the right skills and knowledge to meet their needs.

Required pre-employment checks had been completed for staff before starting work. New staff received an induction, including opportunity to shadow experienced staff until they were confident. Staff told us they felt there were enough of them to provide safe care and said they received regular training and supervision.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

At the last inspection we identified shortfalls with the infection prevention and control systems in the service. At this inspection this had improved.

People told us the service was always kept clean. We observed the home was now clean in all areas. Staff followed good infection prevention and control practice, to help keep people safe. Staff said they had completed infection prevention and control training and had access to all the equipment they needed.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

At this last inspection we identified shortfalls in the way medicines were managed. This had improved at this inspection, and people were receiving safe support.

People told us staff provided good support for them with their medicines. Staff received training in the safe management of medicines, and a manager observed their practice to ensure they were doing this safely. Staff kept accurate records of the medicines people had been supported to take and medicines were stored safely. Some staff had completed additional training and competency assessments by community nurses, enabling them to support people with more complex medicines.