CQC report explained · a nursing home
What the CQC found at Everdale Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Everdale Grange was rated Good after improvements, with kind and safe care, but some people found communication with staff difficult.
The inspection was unannounced and took place on 31 October 2023. Inspectors spoke with people, relatives, staff and visiting health professionals. They also observed care and checked records, medicines, training, policies and quality checks.
The home was rated Good overall, and Good for Safe, Effective, Caring and Well-led. Inspectors found enough staff, safe medicine systems, clean surroundings, good support with food and health needs, and kind care that respected people's dignity and choices.
The home had previously been rated Requires Improvement, with breaches of regulations. Inspectors found that improvements had been made and the home was no longer in breach. This was a focused inspection, so Responsive was not inspected and its previous rating was used in the overall rating.
Safe staffing and medicines
The home had enough staff with the training and skills needed to support people safely. Medicines were received, stored, given and disposed of safely.
“Staff were recruited safely. Staff records included all required information, to evidence their suitability to work with people” from the report
Health and rehabilitation support
Staff worked with health professionals, including doctors, district nurses, physiotherapists and occupational therapists. People on the rehabilitation unit had access to an on-site therapy team.
“G.P.'s routinely visited the service each week and told us staff responded effectively to any changes related to changes in people's health.” from the report
Food and drink
People's nutritional and hydration needs were met, with regular meals, drinks and snacks. The report says meals reflected people's beliefs and cultural needs.
“People's nutritional and hydration needs were met. Meals and drinks were served regularly throughout the day.” from the report
Improved management
The management team responded to feedback and improved records and monitoring. The home also used feedback from people, relatives and staff to make changes.
“The registered manager implemented improvements throughout the inspection.” from the report
Communication with some staff
needs fixingSome people found it difficult to be understood by staff whose first language was not English. Some staff also said this could affect how information about people's needs was shared.
“Some people said they struggled to be understood by some staff whose first language was not English” from the report
- 01How will you make sure a person who finds English difficult can communicate their needs, questions and choices?
- 02How do you check that information about people's needs is shared clearly between staff?
- 03How often are care records and Personal Emergency Evacuation Plans reviewed and updated?
- 04How do you check blood sugar monitoring records and other medicine information is recorded accurately?
- 05What was the previous rating for Responsive, and what changes have been made in that area since the last inspection?
This was an unannounced focused inspection of Safe, Effective, Caring and Well-led; Responsive was not inspected and its previous rating was used for the overall rating. This explanation was written from the published report of 23 November 2023 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, July 2022
Rated Requires Improvement; inspectors found risks around choking, infection control, consent and management, although activities and complaints handling were good.
Inspectors made an unannounced comprehensive visit on 3 and 4 May 2022. They spoke with people, relatives, staff and visiting professionals. They observed care and reviewed care, medicine, recruitment and management records.
The home had enough staff and people said they felt safe. However, some swallowing and choking risks were not managed safely. Inspectors also found problems with infection control, including dirty surfaces, missing soap and incorrect use of masks. Guidance for some as-needed medicines was missing but was added during the inspection.
People were not always supported to make their own choices under the law. Some restrictive practices were used without the necessary mental capacity assessments. Staff interactions were mixed, although relatives generally described staff as caring. Activities, personalised care, complaints handling and end of life care were areas inspectors rated positively.
The overall rating fell from Good to Requires Improvement. Safe, Effective, Caring and Well-led were all rated Requires Improvement. Responsive was rated Good. The provider was asked to improve and said it had started making changes, which CQC will check.
Enough staff
Inspectors saw enough staff and people’s needs were responded to quickly. Recruitment checks were also completed safely.
“We saw there were enough staff. People's needs were responded to quickly.” from the report
Activities and individual needs
People were offered varied activities, including activities suited to their interests. Religious, dietary and communication needs were recorded and supported.
“We saw people were offered a variety of activities. They seemed to engage positively with these activities.” from the report
Health professional support
The home made prompt referrals and visiting professionals spoke positively about communication and how staff followed their advice.
“External health professionals spoke highly of the communication with the service.” from the report
Choking and swallowing risks
seriousSome people were given food or drinks that were not suitable for their swallowing needs. This increased the risk of choking.
“People's swallowing and choking risks were not always safely met.” from the report
Infection control
seriousInspectors found dirty surfaces, no hand soap in a communal bathroom for a full day, poor hand hygiene and masks not always worn correctly.
“We were not fully assured that the provider was promoting good hygiene practices at the premises.” from the report
Consent and restrictions
seriousSome people were subject to restrictions without the required assessment of their ability to make the relevant decisions. This included decisions about personal care, food and constant one-to-one support.
“People were subject to restrictive practices without assessment of their mental capacity.” from the report
Mixed staff interactions
needs fixingInspectors saw some staff not responding to people or not explaining care before carrying it out. Other interactions were positive and relatives generally felt staff were caring.
“We observed some mixed quality of staff interactions with people.” from the report
Weak management checks
seriousAudits and governance systems had not reliably identified or resolved important risks. The home also did not notify CQC about safeguarding incidents when it was legally required to do so.
“Governance systems were not always effective to oversee high quality care.” from the report
- 01What has been changed to make sure every person's food and drink matches their swallowing needs?
- 02How do you now check that thickening powder, hand sanitiser and other potentially harmful items are kept safely?
- 03How are mental capacity assessments and best-interest decisions completed before any restrictions are used?
- 04What changes have been made to cleaning, hand hygiene and mask use since the inspection?
- 05What evidence can you show that your action plan has fixed the problems identified by CQC?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control; the previous overall rating was Good. This explanation was written from the published report of 8 July 2022 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 Everdale Grange
4 rated inspections over 5 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2022Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- November 2020Inspected but not ratedSafe: Inspected but not rated
- February 2020Goodstayed GoodSafe: GoodWell-led: Good
- April 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- March 2018
Registered with the Care Quality Commission on 12 March 2018.
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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