Everdale Grange

Updated 23 November 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of 3 inspectors, a specialist advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Everdale Grange is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Everdale Grange is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there were 2 registered managers in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection

During the inspection

We spoke with 5 people who used the service and 5 relatives about their experiences of the care provided. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with 17 members of staff including care staff, a nurse, the pharmacist, managers including compliance managers, the registered manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We liaised with 5 external health professionals who visited the service to gather feedback on the care provided.

Following our visit we continued to seek further information related to people’s care records, policies and procedures, staff training, quality monitoring and auditing processes as part of the inspection.

Updated 23 November 2023

About the service

Everdale Grange is a residential care home providing accommodation for people who require personal and nursing care for up to 68 people. The service provides support to older people, some of whom are living with dementia, people with a physical disability, mental health needs, sensory impairment and younger adults. At the time of our inspection there were 67 people using the service.

Everdale Grange is comprised of 2 separate buildings. In the first building are the Windsor and Tudor units. The Windsor and Tudor areas support people with long term nursing and personal care needs. The second building is the Sovereign unit, which focuses on short stay placements for people with rehabilitation potential. It has an onsite therapy team, who are funded separately by health partners.

People’s experience of using this service and what we found

People's safety was underpinned by the provider's policies and processes. Lessons were learnt and improvements made through the analysis and reporting of accidents, incidents, safeguarding concerns and investigations.

Potential risks related to people's care were assessed and included improvements to records to support a safe evacuation of people from the service in an emergency, and greater detail of the mitigation of risk linked to people’s care. Medicine systems were managed safely. People were supported by sufficient staff who had undergone a robust recruitment process and had undertaken training in topics to promote safety.

People lived in an environment which welcomed visitors and was well maintained and clean, with safe infection and prevention measures.

Records related to the assessment of people’s capacity to make informed decisions had improved. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People’s health and wellbeing needs were assessed, which included a tailored approach dependent upon the reason for a person’s admission to the service. The assessment process for people admitted for the purpose of rehabilitation, included assessments undertaken by occupational therapists and physio therapists, funded by health partners.

Staff had the knowledge and experience to meet people’s needs. People’s dietary needs were met, which included diets to suit their health, beliefs and culture. Staff liaised effectively with health care professionals to achieve good outcomes for people, confirmed by visiting professionals.

People and family members were positive about the kindness and compassion of staff, and of their commitment to promote people’s dignity. People were supported to practice their beliefs and celebrate their diversity. The cultural diversity of both people and staff was mixed, this provided for some people difficulties in making their needs understood, whilst for others it meant staff could speak with them in their first language.

The registered manager and management team were responsive throughout the inspection and implemented changes throughout the inspection and in response to our feedback. The provider had systems in place to monitor and improve the quality of the service provided, which was underpinned through consultation with people, their relatives and staff.

Staff received support, through training and supervision to promote good quality outcomes for people and attended regular meetings to share information and good practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement published 8 July 2022 and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

When we last inspected Everdale Grange on 3 and 4 May 2022 breaches of legal requirements were found. This inspection was undertaken to check whether they were now meeting the legal requirements.

We undertook a focused inspection to review the key questions of safe, effective, caring and well-led only. For the key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Everdale Grange on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.