Evelyn House

Updated 21 April 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, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Service and service type

Eveylyn House is a 'care home'. People in care homes receive accommodation and nursing or personal care as 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. However, the day to day running of the service was managed by another person and we refer in this report to them as the service manager.

Notice of inspection

The inspection was carried out on 3 March 2021 and was announced. We gave a short period notice of the inspection as we were mindful of the impact and added pressures of Covid-19 pandemic on the service. This meant we took account of the exceptional circumstances and requirements arising as a result of the COVID-19 pandemic.

The inspection was undertaken by two inspectors.

What we did before the inspection:

We reviewed information we had received about the service from notifications to CQC, and information from other key stakeholders. The provider was not asked to complete a provider information return prior to this inspection due to the timing of the inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection:

We spoke with three people at the care home, three members of staff and the service manager.

In addition to talking with people, we spent time observing the daily life in the home and we looked around the building to check the service was safe and clean.

We looked at care records for two people, infection control documents and we checked the electronic medicines system. We checked that maintenance and building checks were carried out regularly and we looked at complaints, accidents and incidents and safeguarding records. We also checked staff training and supervisions.

After the inspection

We asked for recruitment records, further information on audits, and clarification on how the service was managed and quality checks undertaken. We also spoke with the registered manager. We had responses from two family members and one health and social care professional regarding the service.

Updated 21 April 2021

Evelyn House is a residential care home providing accommodation and personal care for up to five people. At the time of the inspection there were five people living at the service. There were two people living in a supported living scheme in the garden, at the back of the property, but they were not provided with activities regulated by the Care Quality Commission, and so are not included in this inspection.

The service supports people with mental health needs, some of whom have brain injury related to substance use.

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

People were positive, in general, regarding staff at the service and we saw kind interactions between staff and people. Relatives and a health and social care professional told us in their view, staff were kind and caring.

We had some concerns regarding the way the service was managed as roles and responsibilities between the service manager and the registered manager were not always clear. This potentially impacted on the quality of the service as there were some management tasks which had not been undertaken and other areas in which the recorded evidence was not always available.

Quality audits were undertaken by the service manager in a number of key areas and the registered manager had identified some key areas that needed improvement prior to this inspection, and had started to make progress in these areas. This inspection has highlighted additional areas that need improvement.

We found some gaps in risk assessments which meant staff were not always provided with guidance in how to safely support people.

Staff had not completed training in all the key areas including safeguarding adults.

The service could not show how they involved staff and people who lived at the service in making decisions as team meetings and residents’ meetings were not regularly taking place.

Medicines management was mostly safe, but there was no guidance for one person who required an ‘as needed’, medicine. Staff competency in the giving of medicines was not checked each year in line with best practice.

Staff were not fully understanding of legislation regarding people’s capacity and their freedom. This meant we could not be sure people were always supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Subsequent to the inspection, staff have training booked in this area, and the service have applied for a formal mental capacity assessment for an additional person.

Care records contained personal information and staff seemed to know the needs of people who had lived there for some time. Health and social care professionals and family members spoke well of the care given to people living there.

The service had a number of systems in place to manage COVID-19. We signposted the service to some minor improvements which were implemented by the time of writing this report.

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

Why we inspected

This service was registered with us on 1 May 2018 and this is the first inspection.

At this inspection we found two breaches of the regulations related to the governance of the service and staffing issues.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

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