16 September 2020
During an inspection looking at part of 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.