CQC report explained · a nursing home
What the CQC found at Evergreen Lodge
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, November 2020
Rated Requires Improvement; inspectors found safe care and better management, but improvements were recent and need to be sustained.
Inspectors visited the home on 16 September 2020. They spoke with people, relatives, staff, managers and outside professionals. They reviewed care records, medicines records, recruitment files and other documents.
The home was rated Good for Safe. Inspectors found that risks were assessed, medicines were managed safely, infection controls were followed and there were enough suitably skilled staff. People said they felt safe and were treated well.
The home was rated Requires Improvement for Well-led. Management and quality checks had improved after a change in management, but many improvements were recent. Inspectors said there was not yet enough evidence that they would continue over time.
This was a focused inspection of Safe and Well-led because of the COVID-19 pandemic. Effective, Caring and Responsive were not reviewed, so their previous ratings were carried forward. The overall rating improved from Inadequate to Requires Improvement, and the home left special measures.
Risk management
People's risks were assessed and staff understood how to manage them. Safety checks were completed and action was taken when problems were found.
“Risks to people were assessed, and measures were in place to manage and monitor people's health, safety and welfare.” from the report
Medicines
Medicines were stored and recorded safely. People received them at the right times and as prescribed.
“People were given their medicines at the times they needed them and as prescribed.” from the report
Infection control
Staff had infection control training, used protective equipment and kept the home and equipment clean. COVID-19 risks were assessed.
“Risks relating to infection prevention and control (IPC), including in relation to COVID-19 were assessed and managed.” from the report
Staffing and safeguarding
Inspectors found enough suitably skilled staff. People said they felt safe, and staff understood how to recognise and report abuse.
“There was the right amount of suitably skilled and qualified staff deployed across the service to safely meet people's needs.” from the report
Involvement and partnership
People and families were involved in care reviews and service feedback. The home worked with health and social care professionals.
“People were engaged with and involved in the running of the service and how their care was provided.” from the report
Improvements not yet established
needs fixingThe management changes and quality systems had only recently been introduced. Inspectors could not yet see enough evidence that the improvements would last.
“However, evidence that could be reviewed was limited as these improvements had been implemented following a change in management after the last inspection.” from the report
Recent history of poor ratings
needs fixingThe home had been rated Inadequate at the previous two inspections. Inspectors said the improvements still needed to be embedded and sustained before the home could be rated Good overall.
“However, the service had been rated inadequate for the last two consecutive inspections and the improvements made need to be embedded and sustained over a longer period to achieve a rating of good.” from the report
- 01What evidence can you show that the improvements made after the change in management have continued?
- 02How are quality checks and audits carried out now, and what happens when they identify a problem?
- 03What are the current ratings or findings for Effective, Caring and Responsive, which were not reviewed in this inspection?
- 04How do you check that medicines continue to be given safely and recorded accurately?
- 05How are families kept informed about care, changes in management and any new concerns?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not reviewed and their previous ratings were carried forward. This explanation was written from the published report of 6 November 2020 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 2020
Evergreen Lodge rated Inadequate and remained in special measures; inspectors found serious safety and management failures despite some improvements.
This was an unannounced inspection on 3 and 4 December 2019. Inspectors reviewed care and medicine records, spoke with people living in the home, relatives and staff, and checked recruitment, training and management records.
The home was not safe. Inspectors found unsafe medicine practices, care that did not always follow people's care plans, and nursing tasks carried out by care assistants without suitable training or authority. Some staff had also suffered needle-stick injuries because safety guidance was not followed. Safeguarding referrals were made after the inspection because of serious concerns about the care received.
There had been improvements since the previous inspection. Recruitment checks, staff training, consent arrangements and the use of restraint had improved. People had enough food and drink, access to activities and healthcare, and many described staff as kind and helpful. However, the overall rating stayed Inadequate because serious risks remained and the home's systems did not identify or correct problems.
Kind staff
Inspectors saw staff being kind and patient. People said staff were helpful and responded when they called for support.
“The atmosphere was calm and homely and staff were kind and patient.” from the report
Improved recruitment and staffing
The home had completed safety checks before employing new staff. Inspectors found staffing levels sufficient to meet people's needs.
“Staff recruited since the last inspection were recruited safely.” from the report
Better consent arrangements
The home had improved how it followed the Mental Capacity Act. Best-interest decisions and deprivation of liberty arrangements were in place where needed.
“Where person's ability to consent to a specific decision about their care was in doubt, the MCA was followed appropriately” from the report
Activities and healthcare
People could join activities and trips, keep up personal interests and see a range of health and social care professionals.
“There were regular opportunities for people to join in activities or trips out.” from the report
Unsafe medicines
seriousPeople sometimes missed prescribed medicines or received them at unsafe times. Staff also lacked suitable guidance for some medicines, including covert medicines.
“Medication management was unsafe and placed people at significant risk of harm.” from the report
Nursing care and risk management
seriousStaff did not always follow care plans or act on serious clinical concerns. Some care assistants carried out nursing tasks without evidence of appropriate training or authority.
“Staff did not always follow people's risk management advice or care plan guidance in the delivery of care in order to keep them safe.” from the report
Poor management checks
seriousThe manager and provider did not have effective systems to monitor care quality and safety. Problems were not consistently found or followed up.
“There were no effective systems in place to monitor the quality and safety of the service.” from the report
Needle-stick safety
seriousSome staff were injured because safe guidance for using and disposing of needles was not followed. This increased the risk of infection.
“Some staff had experienced needle-stick injuries (wounds caused by needles that accidentally puncture the skin).” from the report
Incomplete end of life planning
needs fixingSome people did not have suitable plans explaining their end of life wishes and preferences. This part of care needed more development.
“Some people did not have suitable end of life care plans in place to advise staff in advance, of their end of life wishes and preferences.” from the report
Privacy and accessible information
needs fixingInspectors found that drying wet hair in a communal lounge was not sufficiently private. Information was mainly written, with no alternative formats such as pictures for some people.
“The practice of drying people's wet hair in the communal lounge was not very dignified or mindful of people's right to privacy” from the report
- 01What has changed in medicine management since this inspection, and how do you now prevent missed or wrongly timed doses?
- 02How do you check that nursing care is delivered as written in each person's care plan?
- 03Which nursing tasks may care assistants carry out, and how do you check their training and competence?
- 04How do you monitor clinical risks, such as diabetes, nutrition and essential medicines, and make sure staff act on warning signs?
- 05What progress has been made with end of life care plans and accessible information for people who need pictures or other formats?
This was an unannounced planned inspection of the whole nursing home, including care, medicines, premises and management, following the previous Inadequate rating. This explanation was written from the published report of 16 January 2020 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 Lodge
4 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- November 2020Requires improvementcurrent ratingup from InadequateSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2020Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- June 2019Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 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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Most charge £980 to £1,230 a week. 37 can care for a couple. 8 years' experience on average.
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