Evergreen Manor Care Home

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 inspection we rated this key question good. At this inspection the rating has remained 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.

When accidents and incidents occurred, staff took appropriate action, including seeking medical attention if required. One staff member told us, “If a resident had a fall, I would tell the nurse and then fill in the (accident/incident) form. You get told things like this at handover. The nurse will tell you if someone needs observing or if they need more help. The care plan also gets updated.”

Effective systems were in place to identify any trends or patterns in accidents and incidents so actions could be taken to mitigate emerging risks. Any lessons learnt were discussed in team meetings.

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.

People’s needs were fully assessed before they moved into the home. This information was used to develop care plans and risk assessments to ensure staff had the information needed to provide safe, personalised care.

Staff knew people well and demonstrated a good understanding of their needs. Staff worked closely with health and social care professionals to ensure people achieved good outcomes. One staff member said, “Sometimes we go in with a doctor but it’s mainly the nurses. They tell us anything we need to know after the visit.”

Feedback shared from the Integrated Care Board (ICB) who worked closely with the home was, “The registered manager knows the residents well and timely resident reviews are completed."

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.

People felt safe living at Evergreen Manor. One person said, “I feel we are all safe here.” Another person told us, “I feel very safe there is someone around all the time.”

Staff had received safeguarding training and understood their responsibilities to keep people safe. One staff member told us, “Abuse is a no, no. Anything I saw I would report to the manger or nurse if the manager wasn’t here. I know our manager would deal with it. It wouldn’t be tolerated.”

Records showed the registered manager had referred safeguarding incidents to the Local Authority (LA) and Care Quality Commission (CQC) appropriately.

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.

Relatives felt staff supported people to manage risks by offering solutions. For example, exploring different options when a person felt unsafe using a commode.

Care records informed staff about risks to people’s health and wellbeing and the action they needed to take to mitigate identified risks. For example, 1 person’s care records included recommendations made by a health care professional to mitigate the risk of them choking. Records confirmed staff had followed this instruction.

Care records had been regularly reviewed and updated where needed.

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

Staff had completed fire safety training. Discussions with staff demonstrated they understood their responsibilities and the action they needed to take to keep people safe in a fire or other emergency. Information staff and the emergency services needed to keep people safe in the event of an emergency was up to date and easily accessible.

The provider had processes in place to ensure premises and equipment was regularly checked and maintained in good order. One staff member told us, “If you see something that needs repairing you report it to the maintenance man or if he’s not here the nurse.” Completed maintenance records confirmed this.

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.

People were happy with the support they received from staff. One person said, “I think there are enough staff here.” Another person told us, “The carers are good, hard-working people who know me well and I feel relaxed when they come to help me.”

Rotas demonstrated staffing levels were maintained and people were supported by a consistent staff team. One staff member told us, “I can honestly say we always have enough staff. The numbers we have means we get time to spend with the residents. We can sit and have a chat. I like that.”

Staff had been recruited safely in line with the provider’s policy and best practice guidance.

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.

The home was clean and well maintained.

Most staff had completed infection and prevention control (IPC) training and practiced good IPC. Staff had access to, wore, and safely disposed of used personal protective equipment (PPE).

The management team regularly completed infection prevention and control audits which highlighted any shortfalls, and the actions needed to address these. However, actions taken had not always been fully effective, for example some staff continued to wear jewellery whilst working. The registered manager assured us this would be addressed.

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.

People received their medicines as prescribed. Staff responsible for medicines management had completed training and their competency to administer medicines safely was assessed.

People were supported to self-administer their medicines safely where appropriate and nursing staff supported them to monitor their health and wellbeing.

Some people had ‘when required’ medicine such as creams and pain relief. Clear guidance and body maps were in place to inform staff where creams and pain patches should be applied on the person’s skin.

Medicines were not always stored safely, as we found a prescribed thickening agent left in an unlocked cupboard. The registered manager took immediate action to ensure this was locked away during our visit.