The Evergreens Care Centre

People’s experience of using this service: People, and their family members said the care they received was much improved since the new management team had been in place. We were told staff were kind, caring and couldn’t do enough for people.

People were involved in decisions regarding their care and their environment. People had been involved in making decisions about décor and menu options. Peoples family members had also been encouraged to get involved in choosing menu options.

Feedback from staff had been sought and the registered manager was keen to engage with the staff team in sharing ideas for continuous improvement and involvement in the running of the home.

Widespread improvements had been made since the last inspection in relation to staffing, care, records, medicine management, environment support and training. Staff told us they were very well supported and they were appropriately trained.

The culture was one of openness and transparency. Staff, people and visitors were complimentary of the approach of the registered manager and the staff team and shared how improvements had been made to the point where visitors would not hesitate to recommend the home to others.

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

Rating at last inspection: Requires Improvement (report published 14 June 2018).

Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve the key question of well-led to at least good. During this inspection we found significant improvements had been made.

Why we inspected: This was a scheduled inspection based on the previous rating. Due to the history of the service we brought the inspection forward slightly to ensure improvements were being sustained.

Follow up: We will continue to monitor the service to make sure people receive safe, compassionate, high quality care. Further inspections will be planned for future dates in line with our inspection programme.

Following an inspection in October 2017 we found widespread concerns and identified multiple breaches in regulations we inspected against. We rated the location as inadequate overall, placed it in special measures and took urgent enforcement action to impose conditions on the provider’s registration. This included not being able to admit anyone new to the service.

We next inspected Stephenson Court on 8 March 2018 and found some improvements had been made but identified continued breaches of a number of regulations we inspected against. The location continued to be rated inadequate, and remained in special measures. The imposed condition to prevent admissions remained in place. The provider had continued to breach Regulations 10, 11, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A new breach of Regulation 15 was identified.

During this inspection we found improvements had been made as documented throughout the report. It is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. The service has been rated requires improvement overall as there are still improvements to be made. Systems and processes needed to be embedded to ensure consistent good practice over time.

Stephenson Court 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.

Stephenson Court can accommodate 46 people in one purpose built building. At the time of the inspection 18 people were using the service, some of whom were living with a dementia related condition.

The service did not have a registered manager. The current manager had been in post since 19 April 2018 and had begun the process of applying for a Disclosure and Barring Service check with the Commission so they could apply to be registered. The regional operations manager had applied to the Commission in March 2018 to be registered, however this had not yet been completed. 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 2008 and associated Regulations about how the service is run.

A home manager and a deputy manager/clinical lead had been appointed. Permanent care staff were being recruited and the use of agency staff had reduced, however night staff were predominantly from an agency. The manager, and staff, reassured us that the agency staff being used were consistent so they knew people’s needs well. We have made a recommendation about staffing.

Improvements had been made to the management of medicines and the medicines optimisation team were supporting the home. We found some minor shortfalls in relation to recording.

We found some risks had not been assessed, for example for two people in relation to moving and handling and choking risks. A list of priority needs had been developed to ensure appropriate care plans and risk assessments were in place. We found risks relating to moving and handling had not been assessed for two people and one person’s care plan in relation to wound management was not clear. Two people’s nutritional needs were unclear. The manager was responsive to these concerns and put steps in place to address them, however, the care plan audit system had not driven the required improvements.

Premises safety checks had been completed and equipment was serviced as required.

The provider had introduced a timeframe for the completion of quality assurance audits and various meetings. The quality assurance system had not yet been fully embedded and the provider had not resolved all the concerns identified at previous inspections. We acknowledged the manager was making changes which were driving improvements.

Systems to monitor and track DoLS assessments and authorisations were in place. Some ongoing improvements were needed with regards to capacity assessments and best interest decisions which the manager was aware of. We have made a recommendation about this.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The polices and systems in the service were being embedded and implemented to support this practice.

People were treated in a kind and caring manner by staff. Their dignity was maintained and staff were able to spend time chatting with people. We observed warm relationships were people sought comfort from staff enjoying holding their hands, chatting and offering the occasional hug.

Staff and relatives confirmed they were happy with staffing levels. Staff, and observations, told us they had time to spend with people and that they were able to meet people’s needs. Relatives were happy that the use of agency staff had significantly reduced.

Staff said they felt supported and valued by the manager. Supervision meetings were taking place, staff were aware of the expectations that they would complete all required training prior to their next supervision. Training trackers were in place to monitor staff whose training was not yet up to date. Appraisals were planned to be completed once the manager knew staff better.

The environment was being improved and plans were in place to deliver further improvements to support people with a dementia to orient around the building.

There had been no complaints made since the last inspection.

You can see what action we told the provider to take at the back of the full version of the report.

We last inspected Stephenson Court on 24 October 2017 and found the provider had breached a number of regulations we inspected against. We rated the location inadequate, placed it in special measures and imposed an urgent condition on the provider’s registration to prevent admissions. Specifically, the provider had breached Regulations 10, 11, 12, 14, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found people were not always treated with dignity and respect. Care and treatment was not provided in a safe way. Care was not always provided with the consent of the person and there was a failure to follow the requirements of the Mental Capacity Act 2005 and associated code of practice. There was a failure to assess, monitor and mitigate the risks to the health and safety of people who used the service and a failure to ensure medicines were managed safely.

The environment was not safe for its intended use. People did not receive suitable and nutritious food and hydration.

Systems and processes to effectively ensure compliance had not been implemented. There was a failure to assess, monitor and improve the quality and safety of the service. There was a failure to maintain accurate, complete and contemporaneous records.

There were not enough suitably competent, skilled staff deployed to meet people’s needs. There was a failure to ensure staff received appropriate support, training, supervision and appraisal as necessary to enable them to perform their duties.

Following the last inspection, we met with the provider to confirm their understanding of the concerns and what they would do to improve the ratings for the key questions of safe, effective, caring, responsive and well-led to at least good. An action plan was received from the provider.

Stephenson Court 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.

Stephenson Court can accommodate 46 people in one purpose built building. At the time of the inspection 24 people were using the service, some of whom were living with a dementia.

There was no registered manager in post. 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 2008 and associated Regulations about how the service is run. The regional support manager informed us of their intention to apply and since we inspected we have received an application to register as the manager. We have also been informed that since the inspection a home manager and a deputy home manager have been appointed.

During this inspection we found continued breaches of regulation.

Medicines were not managed safely. Provider audits had not been effective in identifying concerns and driving improvements. The medicines optimisation team had also been involved in reviewing the management of medicines and also found ongoing concerns. Since the inspection the medicine optimisation team have conducted a further audit and have noted some improvements.

There were ongoing concerns with regards to staffing and staff deployment. There were significant nurse and care staff vacancies which were being covered by agency staff. People, relatives and staff raised concerns about staffing and the impact it was having on care. Staffing levels were above that identified on the provider’s dependency tool, however we remained concerned about the effective deployment of staff.

Care plans were in place, however the quality varied and they were not always reflective of people’s current needs. Some were not detailed and some short term care plans remained in place over a month after the short term care need had been met.

Staff said they did not feel supported. We were told supervision meetings should happen every two months however this standard was not met. Induction for new staff was limited and didn’t detail time to get to know people and read their care plans.

Training had improved however there were still some gaps, and the provider’s target of 85% compliance had not been met.

Two people had not had authorised DoLS in place for over a year. One person’s care records documented that they had an authorised DoLS in place when they did not.

The premises had not improved to support the orientation of people living with a dementia. Fire zones had changed and staff had not been informed of the changes and agency nurses who were in charge of the building at night had not been part of a fire drill at the premises. Since the inspection we have received confirmation that agency nurses have completed fire drills.

There had been one complaint which was recorded but there was no outcome detailed.

Quality assurances processes had not been fully implemented which meant there was no effective system to assess the quality and safety of the service. Audits of care plans had not been completed so concerns had not been identified.

Some improvements had been made in relation to meeting people’s nutritional and hydration needs. Activities had improved and people were enjoying the increased contact they were having with other people.

The overall rating for this service is 'Inadequate' and the service therefore continues to be in 'special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We last inspected Stephenson Court on 6 July 2017 and found it was meeting all legal requirements we inspected against. We rated the service ‘Good’ in all domains. At this inspection we found the provider was failing to meet legal requirements and we have rated the service ‘Inadequate’.

Stephenson Court 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. Stephenson Court accommodates 46 people in one building and at the time of the inspection there were 32 people using the service.

The service did not have a registered manager. The current manager had been in post for 11 months at the time of the inspection. Following the inspection the provider informed us the manager had left the organisation.

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 2008 and associated Regulations about how the service is run.

At this inspection we found the provider had breached regulations in relation to safe care and treatment, dignity and respect, consent, meeting nutritional and hydration needs, staffing and good governance.

There were widespread and significant concerns about the leadership and management. . Quality assurance systems had not been followed, so areas for improvement had not been identified.

The concerns we found during the inspection had not been recognised by the manager or area manager and no action had been taken to improve the quality of the service.

Care documentation was not accurate, up to date or sufficiently detailed to ensure people received care that was appropriate and safe. Care plans had not been updated in response to people’s changing needs, nor had they been appropriately reviewed. Some risks had not been identified and assessed. Other risks had been identified but records contained inaccurate information or failed to mitigate and manage concerns.

We found nurse call bells looped behind furniture in the first floor lounge which meant people could not readily summon support. Items of furniture had been placed in front of the internal fire doors. This would have prevented closure had the fire alarms sounded. Dental cleaning products, uncovered razors and out of date prescribed creams were not securely stored in people’s rooms.

People’s nutritional and hydration needs had not been appropriately assessed. Care records contained contradictory information about people’s diets and fluid intake that placed them at risk of harm.

There was evidence of involvement from external health care specialists. However, the advice and guidance they gave was not always included in care records or followed.

People’s medicines were not managed safely. Protocols were not in place to ensure ‘as and when required’ medicines were administered appropriately. There was unsafe recording and we could not be sure people had creams applied as prescribed as there was no documentation in place.

People were not supported to have maximum choice and control of their lives and staff did support people in the least restrictive way possible; the policies and systems in the service did not support this practice.

People were not always treated with dignity and respect. There was limited evidence of involvement in care planning by people and/or their families and loved ones.

Staffing levels were based on the number of people living at the home and did not take account of people’s needs and dependencies. Staff told us they did not have time to meet people’s needs.

Staff had not received the appropriate support, supervision and training to enable them to care for people appropriately. There was no information in relation to nurses competency in relation to catheter care, specialist feeding techniques or wound care.

We have made a recommendation about the environment and meaningful activities for people living with a dementia.

Staff knew how to report any concerns in relation to safeguarding and people told us they felt safe and cared for.

Complaints were logged and were being investigated.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Stephenson Court provides care and accommodation for up to 46 people with nursing or personal care needs. Some of the people who used the service had a dementia type illness. On the days of our inspection there were 40 people using the service.

At the time of our inspection visit the service did have a registered manager in place, however, that manager had left employment and had applied to CQC to de-register. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had been in post for several months. They had applied to CQC to become the registered manager and their application was being considered.

Stephenson Court was last inspected by CQC on 29 April 2016 and was rated Requires Improvement overall.

At the previous inspection it was identified that staff mandatory training was not up to date and the mealtime experience for people varied greatly depending on which dining room they were seated in. During this inspection we found staff were suitably trained and the training was up to date. We found mealtimes were a pleasant experience for all the people who used the service and staff attended to people’s needs in a timely manner. This meant the provider had taken action to address the issues identified at the previous inspection.

Accidents and incidents were appropriately recorded and risk assessments were in place. The registered manager understood their responsibilities with regard to safeguarding and staff had been trained in safeguarding vulnerable adults.

Medicines were stored safely and securely, and procedures were in place to ensure people received medicines as prescribed.

The home was clean, spacious and suitable for the people who used the service and appropriate health and safety checks had been carried out.

Some people who used the service, and family members, raised concerns regarding the number of staff leaving the home. However, observations carried out during the inspection and reviews of rotas found there were sufficient numbers of staff on duty in order to meet the needs of people who used the service. The provider had an effective recruitment and selection procedure in place and carried out relevant vetting checks when they employed staff. Staff received regular supervisions and appraisals.

The provider was working within the principles of the Mental Capacity Act 2005 (MCA) and was following legal requirements in respect of Deprivation of Liberty Safeguards (DoLS).

Care records contained evidence of people being supported during visits to and from external health care specialists. People were protected from the risk of poor nutrition and staff were aware of people’s nutritional needs.

People who used the service and family members were complimentary about the standard of care at Stephenson Court. Staff treated people with dignity and respect and helped to maintain people’s independence by encouraging them to care for themselves where possible.

Care plans were in place that recorded people’s wishes for their end of life care.

Care records showed that people’s needs were assessed before they started using the service and care plans were written in a person-centred way. Person-centred is about ensuring the person is at the centre of any care or support plans and their individual wishes, needs and choices are taken into account.

Activities were arranged for people based on their likes and interests and to help meet their social needs. The service had good links with the local community.

People and family members were aware of how to make a complaint, however, they had no complaints to make about the service.

The provider had an effective quality assurance process in place. Staff said they felt supported by the manager and enjoyed working at Stephenson Court. People who used the service, family members and staff were regularly consulted about the quality of the service via meetings and surveys. Family members told us the atmosphere was friendly and it was a nice place for their relatives to live.

This inspection took place on 27 and 29 April 2016 and was unannounced. We last inspected this service in April 2014, at which time we found them to be meeting all of the regulations that we inspected.

The manager of the service had been in post since January 2016 and had started the process to apply to become the registered manager. 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 2008 and associated Regulations about how the service is run.

There were policies and procedures in place to ensure the smooth running of the service. These included a safeguarding policy which staff told us they understood along with their responsibilities towards protecting people from harm or improper treatment.

People told us they felt safe living at Stephenson Court. Recording and management systems were in place to support the staff to provide the service. We found that staff were using the systems well which enabled them to provide safe, good quality care. Record keeping was found to be accurate and up to date amongst the records we reviewed.

Everyone we spoke with told us they had no major concerns about staffing levels, although people, relatives and staff all told us that high sickness absence levels amongst the staff occasionally impacted on care delivery.

Checks on the safety of the home were routinely carried out by maintenance staff and by external contractors where necessary. Personal emergency evacuation plans were in place.

Medicines were managed in line with safe working practices. We observed a nurse administer medicines during the inspection which was handled safely and hygienically. Medicine administration records were well maintained.

Accidents and incidents were recorded and monitored to identify trends. Staff used this information to update care records and record reduction and preventative measures in risk assessments. People were referred to external healthcare professionals as necessary.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes and hospitals. We found that the manager had a thorough understanding of the principles and had acted in accordance with the law.

Staff received an induction and were trained; formal staff supervisions and appraisals had taken place with the staff whose records we reviewed. Staff attendance at regular refresher training was poor but the manager had an action plan in place to address this. Staff told us they felt supported by the manager and senior staff.

People were supported by staff to maintain a well-balanced, healthy diet. Food looked appetising and nutritious. The staff approach to person-centred care at mealtimes was varied which meant some people did not have a positive experience during these times.

We observed staff respected people, and their privacy and dignity was maintained. Staff displayed caring and kind attitudes and treated people as individuals, however we found that a small group of staff did not display these behaviours during a lunchtime observation. We saw all other staff offered people choices and encouraged them to make decisions about daily life where appropriate.

People participated in a range of activities. The service was developing their activities programme to better suit the needs of the people who used the service. Staff supported people to maintain links by welcoming family, friends and visitors into the home.

Everyone we spoke with told us they knew how to complain and would do so if necessary. Complaints were recorded and investigated as necessary and the manager had shared complaints with external bodies as required. ‘Residents/Relatives’ meetings and quarterly surveys were used to gather feedback about the home and the service provided. Health and social care professionals and other visitors were also asked to give their opinions on the service.

The manager held records which showed the quality and safety of the service was monitored through audits and an internal inspection process.

We considered all the evidence we had gathered under the regulations we inspected. We used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This is a summary of what we have found.

Is the service safe?

The provider had effective systems in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.

We saw risk assessments had been completed for people who were assessed as being at risk of falls. These risk assessments were held with the care plans of people who used the service and had been read by all members of staff.

We saw people were safe and protected from abuse.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. No applications had needed to be submitted at the service. We saw policies and procedures were in place and all staff had received training in the Mental Capacity Act 2005 (MCA) and DoLS.

Is the service effective?

People were treated with respect and dignity. People who used the service were asked about the support they received and if they understood their rights. They were given the information they needed to make an informed decision about their care.

People were supported to have adequate nutrition and hydration and were provided with a choice of what they liked to eat and drink.

Is the service caring?

People's preferences, interests and needs were recorded and staff were able to give

examples of these when we spoke to them.

People's health and care needs were assessed with them and they were involved in this process.

People we spoke with were positive about the care they received from the service.

Comments included, "I have everything I need' and 'I am looked after well here'.

Is the service responsive?

There was an effective system in place to record and monitor complaints. Complaints were taken seriously and responded to appropriately.

We saw evidence that care staff identified changes in people's needs and acted to make sure they received the care they needed.

Is the service well led?

We saw there was a manager in post who was registered with the Care Quality Commission.

The staff we spoke with were all aware of the complaints, safeguarding and whistle

blowing procedures. Staff demonstrated how to identify and report abuse. They told us they would immediately report any concerns they had about poor practice and were confident these would be addressed.

The service had a quality assurance system in place that included the use of surveys from people who used the service.

People told us they were happy with the care they received and staff checked they were in agreement with it. We saw staff consulted people before they provided care and support.

We found people's needs were assessed and care was planned in line with their needs. One person said, 'I like living here, everyone is so friendly, it's like home.' One relative said, 'They really look after mam well here.'

We saw that the provider had a safeguarding policy in place which detailed the actions to be taken should staff have concerns about care or witness a safeguarding incident.

At the time of this visit there were enough qualified, skilled or experienced staff available to meet people's needs. Staff responded promptly to requests for assistance.

There was an effective complaints system available and a clear way of identifying complaints. We found that comments and complaints people made were documented and responded to appropriately.

We spoke with nine people and four relatives to find out their opinions of what the care and support was like at the home. People and relatives told us they were happy with the care and treatment at the home. One relative with whom we spoke informed us, 'X has been here for two and half years. The care is excellent ' and if it wasn't I would tell you.' We concluded that people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

People told us that there was enough equipment to meet their needs at the home. One person commented, 'I've got this special cushion that I sit on which is good.' We concluded that there was enough equipment to promote the health, independence and comfort of people who used the service.

We found that appropriate checks were undertaken before staff began work at the service. A relative told us, 'All the staff are lovely, it's as though they have all been handpicked.'

People and relatives told us they felt able to raise concerns or comments about the service with staff. We concluded that complaints were investigated and resolved, where possible, to their satisfaction.