Evergreen Lodge

Updated 6 November 2020

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by an inspector, medicines inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Evergreen Lodge 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.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We announced the inspection visit 48 hours before it took place. This was because we needed to give time to prepare in advance for our visit due to the COVID-19 pandemic.

Inspection activity started on 14 September 2020 and ended on 21 September. We visited the service on 16 September 2020.

What we did before the inspection

We reviewed the information we received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all this information to plan our inspection.

During the inspection

We spoke with five people who used the service about their experiences of the care provided. We contacted 10 family members by telephone about their experiences of the care provided. We also spoke with the registered manager, deputy manager, clinical lead and five members of staff including nurses, care workers and the activities coordinator. We reviewed a range of records. This included seven people’s care records and multiple medication records. We looked at the recruitment files for two staff employed since the last inspection.

After the inspection visit

Due to the impact of the COVID-19 pandemic we limited the time we spent on site. Therefore, we requested records and documentation to be sent to us and reviewed these following the inspection visit. We also contacted four external health and social care professionals to seek their views on the service and the care provided. In addition, we received further feedback from family members.

Updated 6 November 2020

About the service:

Evergreen Lodge is a care home that provides accommodation for up to 40 people who need help with nursing and personal care. At the time of our inspection 28 people lived in the home. Some people living in the home lived with dementia or other mental health issues.

At our previous inspection in December 2019 the provider was in breach of regulations. At this inspection we found enough improvements had been made and the provider was no longer in breach of regulations. However, evidence that could be reviewed was limited as these improvements had been implemented following a change in management after the last inspection. The focus now needs to be on further embedding and sustaining improvements over a longer period of time in order to achieve an overall rating of good.

People’s experience of using this service and what we found

People and their family members told us they had seen improvements in the quality of care and support people received at Evergreen Lodge. One family member told us, “Since [Name] has become registered manager, we have noticed improvements in the environment, structure, communication and all standards.”

Risks to people were assessed and their safety was monitored. Regular checks were carried out on the safety and cleanliness of the environment and equipment and prompt action was taken to mitigate any risk identified. Risks in relation to aspects of people's direct care was assessed and measures put in place to guide staff on how to keep people safe. People’s safety was monitored, and outcomes recorded in line with risk management guidance.

Medicines were safely managed by staff with the right training and skills. Medication administration records were kept up to date with details of people’s prescribed medicines and instructions for use

People were safeguarded from the risk of abuse. People told us they felt safe and were treated well and family members told us they were confident their relatives were safe. The registered manager and staff were knowledgeable about the different types and indicators of abuse. Allegations of abuse were managed in line with the providers and the local authority safeguarding procedures. Clear records of incidents of a safeguarding nature were maintained.

The providers systems and processes for assessing, monitoring and improving the quality and safety of the service were used effectively. Checks and audits were completed in line with the providers quality assurance framework and areas for improvements were identified and action taken. Records were regularly reviewed, kept up to date and checked for accuracy.

People, staff and family members told us they were engaged and involved in the running of the service and they were provided with opportunities to feedback about their experiences of the care provided. Family members and staff spoke positively about how well the service was run and the improvements made since the registered manager had been in post. There was good partnership working with others including external health and social care professionals.

Risks relating to infection prevention and control (IPC), including in relation to COVID-19 were assessed and managed. Staff followed good infection, prevention and control (IPC) practices.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 15 January 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for ‘Evergreen Lodge’ our website at www.cqc.org.uk.

Why we inspected

A decision was made for us to inspect, examine and follow up what improvements had been made since the last inspection in December 2019. Due to the COVID-19 pandemic, we undertook a focused inspection to only review the key questions of Safe and Well-led. Our report is only based on the findings in those areas reviewed at this inspection. The ratings from the previous comprehensive inspection for the Effective, Caring and Responsive key questions were not looked at on this occasion. Ratings from the previous comprehensive inspection for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

Follow up

We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

This service has been in special measures since April 2019. During this inspection, the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in special measures.