Evington Grange

Updated 4 February 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.

Inspection team

The inspection was carried out by one inspector.

Service and service type

This service is a residential home. It provides personal care and accommodation to people with mental health needs, people with drugs and alcohol issues and younger adults.

The service had a manager who was registered with the Care Quality Commission. This means that when a manager is registered, they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. In a pre-planned move to other employment, the manager had left the service by day two of the inspection.

Notice of inspection

The inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We 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 used all of this information to plan our inspection.

During the inspection

We spoke with four people who lived in the home about their experience of the care provided. We also spoke with two members of care staff, the registered manager, the nominated individual and the deputy manager.

We reviewed a range of records. This included three people’s care records and medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

The nominated individual sent us additional evidence after the inspection visit to follow up on the issues raised in the report.

Updated 4 February 2020

Evington Grange is a residential care service providing personal care and accommodation to people. At the time of the inspection the service was providing personal care to six people.

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

At our last inspection the provider had failed to keep people safe and comprehensively monitor the quality of the service. The provider had not undertaken regular fire checks and lacked a comprehensive medicine management system. There were insufficient audits of medicine. At this inspection we found the provider had made improvements. Systems and processes were in place to keep people safe. There had been an improvement in assessing and monitoring the quality of care provided, though this had not always shown what action had been taken to identified issues.

People felt safe with staff from the service. Staff understood how to protect people from the risk of harm and understood potential signs of abuse. Care plans provided guidance for staff to follow, which staff had read and understood. Risk assessments reduced risk for people. Staff went through a recruitment process so that the provider only employed suitable staff, though this needed to be made more robust.

Systems were in place to monitor the quality of care and support people experienced through quality assurance systems and processes to improve the service though actions identified were not always evidenced as being carried out.

People received their medicines as prescribed and they were protected from the risk of infections through staff working practices. There were enough staff to meet people’s needs. Staff undertook induction and specialist training which provided knowledge and skills to do their job well and effectively meet people’s needs.

People were provided with care and support that ensured they had good nutrition and hydration. They had access to healthcare that maintained their health and wellbeing. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible.

Staff knew people well. People had developed positive relationships with staff which helped to ensure good communication and support. Staff respected people’s privacy and dignity. They supported people to be independent.

People were involved and consulted when deciding how support was provided. Staff knew and understood the needs of the people using the service and care was provided based on their assessed needs. Staff were responsive to changes in people's needs to ensure they received help to maintain their health and well-being.

People knew how to raise any concerns or make a complaint. The provider had a system in place to respond to complaints to put things right. The complaints policy provided information about how these would be managed and responded to.

People and staff spoke positively about the management and leadership of the service. They said staff were very friendly and caring, and they had built good relationships with them.

The service worked in partnership with external agencies to ensure people achieved good outcomes from their care and support.

Rating at last inspection:

The last inspection on 28 September 2018 rated the service as requires improvement.

Why we inspected:

This was a planned inspection based on the last rating.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

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