CQC report explained · a residential care home
What the CQC found at Evendine House Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Staff understood safeguarding, risks were reviewed, staffing levels were based on people's needs and medicines were managed safely.
- Effective?
- Good
- Staff received training and support, people had access to health professionals and their eating and drinking needs were monitored. Staff followed the Mental Capacity Act and used the least restrictive approach.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff supported people to make day-to-day choices and encouraged independence.
- Responsive?
- Good
- Care plans included people's life histories, preferences and routines, and were regularly reviewed. People were offered activities, support to keep in touch with others and care that reflected their end-of-life wishes.
- Well-led?
- Good
- The registered manager and provider checked the quality of care and encouraged feedback. Inspectors found improvements in oversight, reporting to the CQC and the use of care planning systems.
What inspectors found, May 2019
Evendine House Residential Home was rated Good; inspectors found kind, safe and personalised care, and said earlier weaknesses had improved.
This was an unannounced inspection. The inspector spoke with people living at the home, relatives, staff and a health professional. They observed care and reviewed care plans, medicine records, recruitment files, complaints and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicine systems, suitable training, good access to healthcare and care plans that reflected people's preferences.
The home had previously been rated Requires Improvement. Inspectors said improvements had been made after earlier concerns about restraint, staff induction, dignity, personalised care and reporting incidents to the CQC. The overall rating had therefore improved to Good.
Kind and respectful care
People felt able to ask staff for help and reassurance. Staff supported people's choices, privacy and independence.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised care plans
The home had introduced an electronic care planning system. Plans included people's preferences, routines, communication needs and important relationships.
“The provider had introduced a new electronic care planning tool which reflected care that mattered to people, including their life histories and preferences.” from the report
Safe medicines and staffing
Inspectors found enough staff to provide help when needed. Medicines were received, stored, given and disposed of using safe procedures.
“People were receiving their medicines when they should. The provider was following safe protocols for the receipt, storage, administration and disposal of medicines.” from the report
Good links with health services
The home arranged support from health and social care professionals and followed their advice. Staff also supported people to attend routine appointments.
“Where people required support from health and social care professionals this was arranged, and staff followed guidance provided by such professionals.” from the report
Improved management
The report says the home had improved its oversight and governance since the previous inspection. The registered manager was described as approachable and supportive.
“Since our last inspection improvements had been made in the oversight and governance of the service.” from the report
Inspectors raised no specific concerns in this report.
- 01What further changes have been made to make the environment more dementia-friendly since the inspection?
- 02How are my relative's care plan and risk assessments reviewed when their needs or preferences change?
- 03How do you check that medicines continue to be given correctly and on time?
- 04How do you make sure there are enough staff when residents need help at the same time?
- 05How are relatives involved in reviewing care and raising concerns?
This inspection looked at the premises and care across all five CQC questions, but the report gives conflicting dates, listing 24 January 2019 as the inspection visit and also saying it was unannounced on 24 April 2019. This explanation was written from the published report of 8 May 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2018
Rated Requires Improvement; inspectors found serious safeguarding and management failures despite enough staff and several areas of kind, personalised support.
Inspectors visited on 15 and 23 March 2018. The first visit was unannounced and the second was announced. They spoke with people living at the home, relatives and staff, and checked care plans, medicines, recruitment records, notifications and quality checks.
The inspection was prompted by two incidents in January 2018 involving physical restraint and injury. Staff had not always reported abuse, and the home had not always told the CQC about important incidents. Recruitment checks, staff inductions and safeguarding training were also incomplete.
Inspectors found enough staff, good infection control, safe medicine storage and access to healthcare. People generally enjoyed the food and activities, and staff knew people well. However, care was not always respectful or person-centred, and the building was not fully suitable for people living with dementia.
The overall rating and all five areas were Requires Improvement. The home was rated Good at the previous inspection in April 2016, so its rating had fallen.
Enough staff
Inspectors found that staffing levels met people's physical and emotional needs. People did not have to wait long for assistance.
“There were enough staff to meet people's physical and emotional needs.” from the report
Food and health support
People were offered choices and variety, with support for nutritional needs. Staff accessed GPs and other health professionals when needed.
“People were encouraged to eat and drink well, and were offered choices and variety.” from the report
Activities and interests
People could continue personal hobbies and join group activities, outings and community opportunities. Activities were shaped partly by people's suggestions.
“People were able to enjoy their individual hobbies and interests, and had the opportunity to take part in internal and external social and leisure opportunities.” from the report
Improvement work started
The acting manager and provider had begun reviewing care plans, medicines, staff supervision and the quality of care. They also created a plan for further improvements.
“The provider and the acting manager had devised a home improvement plan for Evendine House Residential Home.” from the report
Safeguarding failures
seriousTwo January incidents involved physical restraint and injury. Staff did not always report the first incident, and not all staff had safeguarding training at the time of the inspection.
“People had not been protected from harm or abuse.” from the report
Poor induction and training
needs fixingSome staff had worked at the home without a structured induction, and not all staff had training in safeguarding and other key areas.
“Not all staff working at the home had received any form of structured induction when they started working at the home.” from the report
Dementia-unfriendly environment
needs fixingThere was no visible signage to help people find their way around, and communal areas did not show the day or time. Plans were in place to improve this.
“At the time of our inspection, there was no visible signage around the home to help people navigate their way around.” from the report
Care was not always respectful
seriousTwo restraint incidents placed one person in an undignified situation. Inspectors could not be assured that care was consistently caring.
“Therefore, we could not be assured the service was consistently caring.” from the report
Important incidents not notified
seriousThe CQC was not always told about notifiable injuries and abuse incidents as required by law. The provider submitted the missing notification during the inspection.
“The CQC had not always been informed of events at the home, as required by law.” from the report
- 01What specific changes have been made since the two January 2018 restraint incidents, and how are you checking that people are safe?
- 02Have all current staff completed safeguarding training, induction and any required refresher training?
- 03Have recruitment records been completed for every member of staff, including formal interviews and the required references?
- 04What changes have been made to signage, clocks and date information to make the home easier for people living with dementia to navigate?
- 05How do you make sure personal care is offered in a person-centred way when someone refuses or becomes distressed?
This inspection looked at all five CQC questions, the premises and care provided, and was prompted in part by two incidents involving physical restraint and injury. This explanation was written from the published report of 25 April 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Evendine House Residential Home
3 rated inspections over 3 years: the service has held its Good rating throughout.
- May 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Evendine House Residential Home →
- April 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Evendine House Residential Home →
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- August 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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