CQC report explained · a residential care home
What the CQC found at Evington Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe, staff understood safeguarding and risks, fire checks were in place, and medicines were given as prescribed. Recruitment checks were generally completed, but one reference had previously been obtained from a client rather than management.
- Effective?
- Good
- People's needs were assessed, staff received induction and relevant training, and people were supported with food, drink and healthcare. One staff member was unclear about their responsibilities under the Mental Capacity Act, and management agreed to address this.
- Caring?
- Good
- People described staff as friendly and caring. Inspectors saw positive interactions, and people said their privacy, dignity, beliefs, choices and independence were respected.
- Responsive?
- Good
- Care plans included people's preferences, routines and life histories, and staff responded to changing needs. People could take part in activities and community visits, although feedback said more activities were needed.
- Well-led?
- Requires improvement
- The provider had quality audits and systems, but some audits were missing and records did not always show that identified actions had been completed. Feedback, meeting suggestions and some maintenance work were not consistently followed through.
What inspectors found, February 2020
Rated Good overall; inspectors found safe, kind and responsive care, but the home was not always well-led.
This was an unannounced inspection on 19 and 30 December 2019. One inspector spoke with four people, two care staff and managers, and reviewed care, medicines, recruitment and management records. Six people were living in the home.
The home was rated Good for Safe, Effective, Caring and Responsive. People said they felt safe, staff were kind, medicines were given as prescribed, and care was based on people's needs and choices.
Well-led was rated Requires Improvement. The provider had improved safety and quality systems since the previous inspection, but did not always show that actions from audits, meetings and feedback had been completed.
People felt safe
People said they felt safe with staff. Staff knew how to recognise abuse and manage risks, and fire checks and medicines audits were in place.
“People felt safe with staff from the service.” from the report
Kind and respectful staff
People described staff as friendly and caring. Inspectors observed relaxed, positive conversations and saw staff offering reassurance.
“People said that staff were friendly and caring and they were treated fairly.” from the report
Personalised care
Care plans recorded people's preferences, routines, interests and life histories. People were involved in decisions about their support.
“Care plans had information about people's preferences and this covered their life histories and likes and dislikes.” from the report
Support for health
People received support with food, drink, appointments, dental care and other health needs. Staff worked with health and social care professionals.
“People were provided with food of their choice after staff asked them what they wanted.” from the report
Quality checks were not fully followed through
needs fixingThe home did not always record what action had been taken after audits, surveys and meetings. Some audits were missing, including checks on training, staffing levels and recruitment.
“Some were missing such as staff training, staffing levels and staff recruitment.” from the report
Feedback was not always acted on
needs fixingPeople's and staff suggestions were collected, but there was not always an action plan or evidence that suggestions had been acted on.
“The minutes of the meeting did not show that people's suggestions had been acted on.” from the report
More activities were requested
minorPeople had activities and community visits, but comments from staff and residents indicated that more activities were wanted. Managers said this would be reviewed.
“There were comments by staff and in residents meetings and surveys that more activities were needed.” from the report
Recruitment records needed to be stronger
minorMost recruitment checks were completed, but one past reference had been obtained from a client rather than management. The manager said measures had since been put in place.
“There was one instance where a reference from a previous employment had been sought from a client of that service, but not from management.” from the report
- 01What action has been completed in response to suggestions from residents' meetings, surveys and staff feedback?
- 02How are audits of staff training, staffing levels, recruitment and maintenance now completed and checked?
- 03What is the plan for replacing the registered manager who left during the inspection?
- 04What extra activities are now available following requests for more trips and activities?
- 05How do you check that all employment references come from an appropriate previous employer or manager?
This was an unannounced inspection covering all five CQC questions; it found improvements since the previous inspection, but Well-led remained Requires Improvement. This explanation was written from the published report of 4 February 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, December 2018
Rated Requires Improvement; inspectors found kind, personalised care but weaknesses in medicines safety and management checks.
This was the home's first rating inspection since it registered in August 2017. Inspectors visited on 28 September and 9 October 2018. They observed care, spoke with people, staff, managers and a health professional, and checked care records, medicines, recruitment, training, complaints and safety records.
People were generally treated kindly and supported as individuals. Inspectors rated the home Good for effective, caring and responsive care. Staff understood people's needs, supported their choices, helped them stay in contact with family and friends, and involved health professionals when needed.
The home was not consistently safe or well-led. Inspectors found gaps in recruitment paperwork, medicines records and checks, out-of-date medicines competency checks, incomplete training records and no recorded fire drill since June 2018. The overall rating Requires Improvement means the home was meeting some important standards, but improvements were needed.
Kind and respectful staff
Inspectors saw staff speaking compassionately with people and supporting their choices, privacy and dignity.
“People were treated with kindness and compassion by a caring staff group.” from the report
Personalised support
Care plans reflected people's mental health, physical health, preferences and goals. Staff knew people's likes, dislikes and support needs.
“People received personalised care that was responsive to their individual support needs.” from the report
Staffing and safeguarding
The home had enough staff for people's assessed needs. Staff understood how to recognise and report possible abuse.
“We found that staff were employed in sufficient numbers to provide support and guidance for people safely.” from the report
Medicines recording and storage
seriousSome medicines instructions and signatures were missing or incomplete. Staff did not always record when as-needed medicines were given, and the room temperature was not monitored.
“Staff mostly recorded the times these additional medicines were required on the back of the MAR chart which is the recognised method of recording, though sometimes not at all.” from the report
Recruitment records
seriousApplication forms did not properly record previous employment or referees. This made it difficult to confirm that references belonged to the correct staff files.
“Recruitment paperwork did not allow the recording of people's previous employment history or referees.” from the report
Fire drill records
needs fixingAlthough fire procedures and evacuation plans were in place, there had been no recorded fire drill since June 2018. The manager said drills would be carried out more regularly.
“We spoke to the registered a manager about the period of time since the last fire drill.” from the report
Weak quality checks
needs fixingAudits did not identify several problems, including gaps in training records, out-of-date medicines checks, incomplete recruitment paperwork and an outdated statement of purpose.
“Quality audits and checks were not used effectively to ensure people were provided with good safe care and support.” from the report
People's meetings and feedback
minorThe home could not produce records of meetings with people, and there was no evidence of the outcomes from questionnaires. Some current residents had not had the chance to take part.
“We asked the registered manager who confirmed the meetings had been arranged but could not produce any record or minutes.” from the report
- 01What changes have been made to medicines records, as-needed medicines instructions, signatures and room temperature checks?
- 02How do you now record previous employment and references for every staff member?
- 03When was the most recent fire drill, and how often are drills now carried out and recorded?
- 04How do you check that staff training, medicines competency checks and recruitment records are up to date?
- 05How are residents now involved in meetings, questionnaires and decisions about changes to the home?
This was the home's first rating inspection and covered all five CQC questions, including direct observations, discussions and checks of care, medicines, staffing, records and the premises. This explanation was written from the published report of 7 December 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 Evington Grange
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- February 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2018Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017
Registered with the Care Quality Commission on 4 August 2017.
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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