Evergreen

Updated 19 February 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of coronavirus, we are conducting reviews to ensure that the Infection Prevention and Control practice was safe and the service was compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place.

This inspection took place on 12 February 2021 and was announced.

Updated 19 February 2021

We inspected Evergreen on 4 and 5 December 2017. We previously carried out an inspection at Evergreen in June 2016 where we found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because we identified concerns in relation to the implementation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We also identified there was a lack of records to demonstrate actions taken in response to audit shortfalls and records were not consistently up to date and detailed. The service received an overall rating of ‘requires improvement’. The provider sent us an action plan and told us they would address these issues by November 2016.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had followed their action plan, and confirm that the service now met legal requirements. We found improvements had been made in the required areas and regulations had now been met. However, further time was required to allow time for changes to be fully embedded into practice. Therefore, the overall rating for Evergreen remains requires improvement.

Evergreen is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Evergreen provides nursing and personal care and accommodates up to 16 people in one adapted building. At the time of the inspection there were 15 people living at the home.

A registered manager was in post, who was also the owner. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Improvements had taken place since our last inspection in relation to the quality assurance system and records. However, these need time to be fully embedded into practice. People’s daily records and other charts were task based and did not fully reflect the support and engagement people needed. Some audits had not been completed and others did not identify the issues we found. Improvements had been made in relation to mental capacity, however, further work is required to ensure these are fully embedded into practice. Mental capacity assessments did not demonstrate how people who had fluctuating capacity were able to make decisions. These did not impact on people and we made a recommendation about this.

Improvements had been made in relation to mental capacity, however, further work is required to ensure these are fully embedded into practice. Mental capacity assessments did not demonstrate how people who had fluctuating capacity were able to make decisions.

The registered manager had identified areas where improvements were needed and work had started to address these. This included ensuring everybody was able to engage in meaningful activities and the completion of cream charts.

People were supported by staff who were kind and caring. They knew people well and had a good understanding of people’s individual needs and choices. They could tell us about people’s personal histories including their spiritual and cultural wishes. People were involved in the planning of their care and offered choices in relation to their care and treatment. Their privacy and dignity were respected and their independence was promoted.

Staff understood their responsibilities in relation to protecting people from harm and abuse. They told us what actions they would take if they believed people were at risk of abuse or discrimination.

Risks to people were identified, appropriately assessed and action taken to keep people safe. Systems were in place to ensure medicines were managed and administered safely. The service was clean and tidy throughout, infection control protocols were followed.

There were safe recruitment practices in place and there were enough skilled and experienced staff to ensure people were cared for safely. Staff received the appropriate training and supervision to ensure they had the appropriate skills to meet people’s needs.

People were supported to eat and drink well. They were provided with choice of meals and drinks each day. People’s health was monitored and staff responded when health needs changed.

There was a positive culture at the home. Staff were involved and informed about changes at the home through handovers and updates throughout the day. The registered manager had good oversight of the home and worked hard to implement changes and improvements.