CQC report explained · a residential care home
What the CQC found at Evergreen House Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People felt safe, risks were assessed and managed, and inspectors saw enough staff to meet people's needs. Medicines systems were safe, although damaged flooring in the medicines room presented an infection control risk.
- Effective?
- Requires improvement
- People's health, dietary and fluid needs were generally supported, and staff had suitable training. However, specific mental capacity assessments had not always been completed or recorded, and some lunchtime arrangements were not suitable.
- Caring?
- Good
- People and relatives described staff as friendly and caring. Staff knew people well, promoted independence, and respected privacy and dignity.
- Responsive?
- Good
- Care plans reflected people's needs, preferences and life histories, and staff responded to changes in health. Activities were available, but some people felt they were not tailored enough to their interests.
- Well-led?
- Requires improvement
- People, relatives and staff spoke positively about the registered manager and communication. However, audits did not consistently identify problems, and identified issues were not always dealt with promptly.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found safe, kind and responsive care, but concerns about consent records and how the home was managed.
This was an unannounced inspection on 07 March 2023. Inspectors spoke with 8 people, 4 relatives and 5 staff. They also reviewed care records, medicines records, repositioning records, recruitment files and the home's quality checks.
People were generally safe, treated kindly and supported according to their individual needs. Medicines were managed safely, staffing levels were seen to be enough, and staff respected people's privacy, dignity and independence.
The home did not always assess or record people's ability to make specific decisions. Some people had delays at lunchtime and could not leave the dining room when they wanted. The home's checks had also failed to identify or promptly resolve some concerns. The overall rating was Requires Improvement, with Safe, Caring and Responsive rated Good, and Effective and Well-led rated Requires Improvement.
Kind and respectful staff
People and relatives spoke positively about how staff treated them. Inspectors saw friendly interactions and found that privacy, dignity and independence were respected.
“Support and personal care was provided in a dignified manner and people's privacy was respected by the staff team.” from the report
Personalised care
Care plans included people's preferences, interests, cultural or religious needs and life experiences. Staff knew people's individual personalities and responded to changing needs.
“Care plans reflected people's cultural or religious needs as well as life experiences, interests and hobbies.” from the report
Enough staff and safe risk management
Inspectors saw enough staff in communal areas and bedrooms. Risks were assessed, and the manager had taken action after an increase in night-time falls.
“We observed staffing throughout the day and saw there were enough staff to support people in both communal areas of the home and where people chose to spend time in their bedrooms.” from the report
Mental capacity records
seriousThe home had considered people's mental capacity but had not assessed or recorded capacity for specific decisions. This could mean decisions were made on someone's behalf without following the law.
“Although people's mental capacity had been considered, people's capacity to make specific decisions had not been assessed or recorded.” from the report
Weak quality checks
seriousAudits had not found missing capacity assessments, inconsistent repositioning records or incomplete recruitment records. A known flooring problem in the medicines room had also not been fixed.
“The provider had failed to establish systems to effectively assess, monitor and improve the quality and safety of the service.” from the report
Lunchtime arrangements
needs fixingSome people waited for their food and, because of the dining room layout, could not leave when they wanted. The manager said the arrangements would be reviewed.
“Some people experienced delays in receiving their food and due to the layout of the dining room were unable to leave when they wanted to.” from the report
Activities not always personalised
minorAlthough a range of group and one-to-one activities took place, some people said there was little to do or that activities did not match their interests.
“I'm bored. There isn't a lot to do. No one has asked me what I would like to do.” from the report
- 01How have you completed and recorded mental capacity assessments for specific decisions since this inspection?
- 02How do you now check that people are repositioned as set out in their care plans?
- 03What has been done to repair the damaged flooring in the medicines room?
- 04How have you changed the dining room arrangements so people can leave when they want and receive food without delays?
- 05How do you find out what activities each person wants and check that the programme reflects their interests?
This was an unannounced inspection covering all five key questions, including infection prevention and control under Safe; the previous overall rating was Good, published on 9 January 2021. This explanation was written from the published report of 19 May 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, January 2021
Rated Good overall; inspectors found safe care, but leadership and incident reporting required improvement.
Inspectors visited on 8 December 2020 and followed up by telephone on 11 December. They reviewed care plans, medicines records, staff recruitment files, training information and quality checks. They also spoke with one person and five staff members.
The home was rated Good for Safe. Inspectors found suitable staffing, safe medicines procedures, regular risk checks and effective infection control. They found no evidence that people were at risk of harm from the concerns that led to the inspection.
The home was rated Requires Improvement for Well-led. Managers had not recognised that two incidents needed to be reported to the appropriate professionals. The manager said processes would be reviewed, and the incidents were reported after the inspection.
This was a focused inspection of Safe and Well-led only. The overall rating remained Good because the other three question ratings were carried forward from an earlier comprehensive inspection.
Safe staffing
Inspectors found enough staff to meet people's needs. Permanent staff and low turnover supported consistency.
“People were supported by sufficient staff, who cared for them with a person-centred approach.” from the report
Medicines improved
Earlier gaps in recording prescribed creams had been addressed. Inspectors found medicines securely stored, fully recorded and regularly audited.
“Improvements were made which ensured staff recorded when administering people's prescribed creams.” from the report
Infection control
The home was clean and inspectors were assured about its arrangements for preventing and managing infections, including the use of protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Positive relationships
Inspectors saw a calm atmosphere and staff providing person-centred care. People and families were encouraged to share their views.
“The home had a calm atmosphere and staff across all areas formed positive relationships with the people living in the home.” from the report
Incident reporting
needs fixingManagers did not recognise that two incidents needed to be notified to the appropriate professionals. There was no reported impact on people, and the incidents were reported retrospectively after the inspection.
“We found two incidents where we had not been notified, however, there was no impact on people using the service.” from the report
- 01What changes have been made to ensure all potentially notifiable incidents are recognised and reported promptly?
- 02How are managers checking that staff understand the process for reporting incidents and safeguarding concerns?
- 03How are medicines audits and records checked now, following the earlier gaps in recording prescribed creams?
- 04How will you maintain the staffing consistency described in the inspection report?
- 05Which ratings were carried forward from the previous comprehensive inspection, and when will the remaining areas be inspected again?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from previous comprehensive inspections. This explanation was written from the published report of 9 January 2021 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 Evergreen House Residential Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Evergreen House Residential Home →
- January 2021Goodstayed GoodSafe: GoodWell-led: Requires improvement
Read what inspectors found at Evergreen House Residential Home →
- November 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2020
Registered with the Care Quality Commission on 1 May 2020.
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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