Evedale Care Home

Updated 1 June 2023

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 Health and Social Care Act 2008.

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

The inspection team consisted of 2 inspectors, a specialist advisor and an Expert by Experience. Our specialist advisor was a registered nurse who had expertise in supporting older people and people living with dementia. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Evedale Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement dependent on their registration with us. Evedale Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since they registered with CQC and sought feedback from the local authority who work with the service. 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 also used information gathered as part of our monitoring activity that took place on 21 February 2023 to help plan the inspection and inform our judgements.

During the inspection

We spoke with 6 people who used the service and 3 relatives about their experience of the care provided. We spoke with 15 members of staff including the regional manager, registered manager, clinical lead, nurses, housekeeper, cook and care staff. We also spoke with 2 healthcare professionals who were visiting the service at the time of the inspection.

We carried out general observations of the way people were supported. We reviewed a range of records, including 7 people's care records. We looked at 4 staff files in relation to recruitment and staff support and a range of records relating to how the service operated and was managed.

Updated 1 June 2023

Evedale Care Home is registered to provide personal and nursing care for up to 64 older people. At the time of our inspection 49 people lived at the home and 3 people were in hospital. Accommodation is provided in a purpose-built building across two floors. One floor provides specialist care to people who lived with dementia.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and autistic people.

Right Support:

Risks associated with people’s care and the environment were not always fully assessed and well managed. We made a recommendation about improving environmental checks. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff were recruited safely and there were sufficient staff to provide people's planned care and support.

Right Care:

Care plans and risk assessments were not always completed in a timely manner. People received personalised care from staff who knew them well and ensured their rights and dignity were promoted and protected. Staff understood their responsibilities to keep people safe and protect from harm.

Right Culture:

Quality monitoring systems and checks were in place. However, further improvement was needed to ensure issues were fully identified and reviewed to ensure action taken was effective. Staff felt supported by the registered manager who promoted an open and inclusive culture. The staff team worked in partnership with a range of professionals to achieve good outcomes for people.

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 requires improvement (published 14 December 2020) and there was a breach 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 regulation.

The overall rating for the service has remained requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This focused inspection was prompted by a review of the information we held about this service. This report only covers our findings in relation to the key questions safe, effective, and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.