We inspected Evergreen Court on 7 and 8 October 2015. The first day of the inspection was unannounced which meant that the staff and registered provider did not know that we would be visiting. We informed the registered provider of our visit on 8 October 2015.
Evergreen Court provides care and support for a maximum number of 17 older people and / or older people living with a dementia. The service provides ground floor accommodation. Bedrooms are single in nature and have en suite facilities which consist of a toilet and hand wash basin. There is one large lounge, a small part of which has been sectioned off to create a quieter area for people to sit and a dining room. The service is situated in Saltersgill and is close to shops, pubs, public transport and The James Cook University Hospital.
The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was also responsible for the management of another service nearby (Lavender Court). They told us that their main base was at Lavender Court but they spent time at Evergreen Court each day. A unit manager was employed to support the registered manager in the running of the service.
People were protected by the services approach to safeguarding and whistle blowing. People who used the service told us that staff treated them well. Staff were aware of safeguarding procedures, could describe what they would do if they thought somebody was being mistreated and said that management acted appropriately to any concerns brought to their attention.
Appropriate checks of the building, equipment and maintenance systems were undertaken to ensure health and safety.
Risks to people’s safety had been assessed by staff and records of these assessments had been reviewed. Risk assessments covered areas such as choking, falls and moving and handling. This enabled staff to have the guidance they needed to help people to remain safe.
We saw that staff had received supervision on a regular basis. The registered manager was a little behind with appraisals having completed seven out of 20 appraisals this year. They told us they were to complete appraisals over the next few weeks.
We looked at a chart which detailed training that staff had undertaken during the course of the year. We saw that there were gaps in training for some of the staff. Where gaps in training were identified we were reassured that training was planned and would take place in the very near future. We saw that 55% of staff had undertaken health and safety training and that 55% of staff had undertaken training in fire safety. We saw that 90% of staff had undertaken training in moving and handling and that 20% of staff had undertaken training in food hygiene and 35% had completed infection control training.
Only 20% of staff had received training on the Mental Capacity Act 2005 and DoLS. The registered manager and staff were unclear about the principles of the Mental Capacity Act 2005. There were assessments about the capacity of individual people to make their own major decisions. The registered manager was not able to describe the steps they had taken in reaching the decision about capacity. Best interest decisions were not fully reflected in care plans.
At the time of the inspection, there were some people who used the service who were subject to a Deprivation of Liberty Safeguarding (DoLS) order. DoLS is part of the MCA and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests.
People and staff told us that there were enough staff on duty to meet people’s needs. We saw that staff had time to spend with people and chat.
In general safe recruitment and selection procedures were in place. The staff recruitment process included completion of an application form, a formal interview, previous employer reference and a Disclosure and Barring Service check (DBS) which was carried out before staff started work at the home. The Disclosure and Barring Service carry out a criminal record and barring check on individuals who intend to work with children and vulnerable adults. This helps employers make safer recruiting decisions and also to prevent unsuitable people from working with children and vulnerable adults. We found that some improvements could be made. The application form did not ask people for end dates of their employment which means that gaps in employment might not be explored. And the references for two people were not from their last employer.
Appropriate systems were in place for the management of medicines so that people received their medicines safely. However the room temperature in which medicine was stored was on occasions too hot. Storing medicines in higher than recommended temperatures could affect the efficiency of the medicines. The registered manager said that the registered provider was aware of the high temperatures and that they were taking action to rectify the concern.
There were positive interactions between people and staff. We saw that staff treated people with dignity and respect. Staff were attentive, respectful, patient and interacted well with people. Observation of the staff showed that they knew the people very well and could anticipate their needs. People told us that they were happy and felt very well cared for.
We saw that people were provided with a choice of healthy food and drinks which helped to ensure that their nutritional needs were met. People who used the service had undergone nutritional screening to identify if they were malnourished, at risk of malnutrition or obese. People were weighed on a regular basis.
People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff to hospital appointments.
Each person had an assessment, which highlighted their needs. Following the assessment care plans had been developed. Care records reviewed contained information about the person's likes, dislikes and personal choices. We saw that some care plans needed more information to help to ensure that the needs of the person were met.
People’s independence was encouraged and they were encouraged to take part in activities. People told us that they were happy with the activities provided by staff at the service.
The registered provider had a system in place for responding to people’s concerns and complaints. People told us they knew how to complain and felt confident that staff would respond and take action to support them.
There were systems in place to monitor and improve the quality of the service provided. However we would question the effectiveness of the auditing system. The majority of the audits were a question with a tick box and as such they did not pick up on some of the areas that we identified during the inspection.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we took at the back of the full version of this report.