The Evergreens Lodge

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We reviewed 8 Quality Statements in this key question. We found the service did not always have sufficient systems and practices in place to keep people safe. We found a breach of regulations in medicines. There needed to be improvements made in pressure care. Fire safety was compromised due to overdue servicing however this was remedied shortly after our assessment. There were sufficient trained staff deployed to support people and relatives were confident their family members were safely cared for.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s relatives were mostly happy with the care they received and told us support was given to their family members by staff who understood how to communicate with them.

Staff members did not comment specifically on learning from accidents and incidents however understood their role should something go wrong. They told us they would report concerns to more senior staff and ensure an accurate record was kept of the event.

The provider had an audit and review process that would, when issues were identified, assess and share any learning with the staff team. However, we noted audits did not always identify problems. We have reported more on this in the medicines and governance sections of this report. This meant that potential learning may be missed.

The registered manager ensured appropriate information was shared with partners such as health and social care professionals.

We received no specific feedback on this theme from partners.

We were not assured all referrals for healthcare support were made as they should be. One person told us they had asked for a carer to tell the deputy manager they needed to see a GP as they felt very unwell. The staff member told the person to wait for a few days to see how they went. The following day another staff member noted low oxygen saturation and called an ambulance. Calling paramedics earlier may not have prevented this person who had pneumonia being unwell but would have enabled treatment to commence earlier and for them to not need to feel as worried as they had.

People told us they did not feel safe because other people would access their rooms without permission. These concerns were expressed by 5 people when we spoke with them at the service. They had different experiences with different people, but all had made them feel unsafe in their own rooms and locking their doors at night was the only means to prevent this happening. They were unhappy about locking their doors in case they had an emergency and staff could not get to them. We spoke with 11 relatives on the telephone, and they were all happy their family members were safe. They reported fewer falls, people having well managed medical conditions and the service having good security so their family members could not leave the premises should this be a risk to them.

Staff knew about different types of abuse and what signs and symptoms they may see should someone be experiencing abuse. Staff were able to explain their role to us should they suspect abuse was taking place, they were also certain the management team would act should they raise concerns. A staff member told us, “If a resident or another carer had concerns about something I would raise it with management for them. At the weekend we can contact them by phone, even for minor things.”

We saw staff were attentive to people most of the time, however, we were concerned the dining room was left unattended for a period of several minutes at lunchtime. Throughout the meal, staff left the room to collect meals or other items however, during this longer period, a person got up, used furniture to steady themselves and accessed an adjoining toilet. We were concerned as they were unsteady when moving. The registered manager assured us there was no one in the area at that time who needed 1-to-1 support with mobility, and no one had a safe swallow plan or were at increased choking risks. We cannot be assured this would not be a routine occurrence, meaning people with more significant needs at mealtimes may be unsupervised.

There was a safeguarding record, complete with log that detailed cases, actions taken, referrals and notifications. These had been thoroughly completed and were a clear record of all noted safeguarding concerns. Staff completed training in safeguarding and updated this regularly.'

People’s relatives had been involved in assessments and care planning, including risk management. People also told us other, more personal risks had been addressed, such as supporting them with medical conditions, or if they had particularly friable skin, risk assessments and plans enabled them to maintain it. However, people told us they were not happy with the response from staff and the management team to people accessing their rooms. Generally, the response was that the person was living with dementia, and nothing could be done to change their behaviours.

Staff told us they maintained regular checks on people and ensured nothing hazardous was left in reach. Another staff member told us they thought keeping people safe was complex, and as they were busy, they tried to keep an eye on people.

We saw staff being attentive in communal areas and supporting people with drinks and care. They supported people with their mobility and responded to call bells promptly.

People had risk assessments in place to assess and mitigate risks including risks caused by their health conditions, the environment and falls. We were not assured all risk assessments were accurate. One person had an epilepsy risk assessment stating their epilepsy was well controlled and “they have been seizure free for many years”. In the summary it stated the person had their last seizure in November 2023. This contradicts the previous statement. While there was minimal impact from this as there was a care plan for epilepsy, it is important staff work to accurate risk assessments as they could, for example, share incorrect information with healthcare professionals or react incorrectly which could potentially cause harm. Some people had been assessed as being at risk of skin damage. Risk assessments had been regularly reviewed. When risks were identified, the plans informed staff how to reduce the risk of harm to people, such as any pressure relieving equipment in use and how often people needed support to change position. We looked at 6 air mattresses that needed to be set according to people’s weight. Two of these were set at the correct weight and the other 4 were incorrect. Staff documented daily that mattress checks had been completed. On the day of the inspection, checks had been carried out, and the status was recorded as “Normal” or “Correct” on all 6 mattresses we checked even though 4 were incorrectly set increasing risk of pressure damage to people. When people needed staff support to change position regularly, the required frequency was written in the care plan. Position change records we looked at showed that in the main, people had their positions changed in line with care plan guidance.

People were concerned about some aspects of the environment that had not been addressed promptly. A fire door that could not be held open due to a faulty magnet not being fixed in a timely way had negatively affected some people who lived with mobility difficulties. One person was concerned at the high temperatures they experienced in their room and though they had told staff about this, the problem continued, particularly in the summer when the sun was strong. We noted there were no blinds at the windows.

Staff told us they received training in relevant areas such as fire safety to ensure they maintained a safe environment. Other staff, for example a housekeeper had also completed training in legionella as they had to flush infrequently used outlets.

We saw the premises were being gradually renovated and improved. As rooms became vacant, ensuites were replaced and rooms redecorated. We saw fire extinguishers had not been serviced by the due date and one of the door release break glass covers had been taped down so would not easily be opened in an emergency. Linen cupboards on the ground and first floor were not locked shut and both held sanitiser. The registered manager advised this was due to missing keys. Rather than give out the last master keys, they were replacing the locks with keypad entry systems. The keys were later found under the mattress of a newly admitted person. We noted one of the Dorgard door closers had a low battery alert sounding and informed the management team. There was an area by the lift on the first floor where seating had been arranged. This was a nice area for people to watch others coming and going. Unfortunately, the seating in this area had a strong odour of urine.

The provider had not ensured servicing of fire extinguishers was done. They had requested the contractor make an appointment to service the items but when there was no response, they had not taken any additional action. Potentially hazardous sanitiser had been left in unlocked cupboards due to keys being lost. This should have been moved as a priority when it was evident the cupboards could not be locked. We requested the Fire Service get in touch with the provider as we were not able to locate a recent check by them. Other aspects of environmental safety such as flushing infrequently used outlets had been completed and a regular environment audit noted areas of concern that may need redecoration or repair.

We received mixed views on staffing numbers. People felt there were not always enough staff, and at weekends they were concerned as there were no management staff from 7 pm on Fridays. This meant decisions made at the weekend could fall to less experienced staff. A person said, “There’s nobody senior here at the weekends. Management closes at 4pm on a Friday.” They went on to tell us about a health incident they experienced which they believed to have been exacerbated by inexperienced staff making decisions. Relatives were happier with the staffing levels – they thought staff knew their family members well and responded to them promptly. The registered manager advised us there were 3 members of the management team, in addition to themself, there was a deputy manager and a head of care. The head of care worked alternate weekends, and currently the registered manager covered for the chef on a Saturday with the deputy manager covering weekends as needed. In addition there was a duty rota. On a weekly basis, the management team would be contactable by phone outside their usual working hours. Effectively there was management cover at the weekends however people were not aware of this.

Staff thought there were sufficient staff deployed across all shifts. They also confirmed they had regular 1-1 meetings with senior staff and felt supported.

We saw staff interacting with people throughout our inspection. There appeared to be sufficient staff deployed.

Staff participated in regular 1-1 supervisions and accessed a wide range of training courses. Staff recruitment records were complete and contained all required pre-employment checks. The provider was currently staffing the service significantly higher than the hours calculated using their dependency tool. This enabled change and improvements to take place.

People and their relatives were happy with the standard of cleanliness and infection prevention and control (IPC) maintained in the service.

Staff told us they were trained in IPC and were clear about the use of IPC. However, while they knew what they should use, in practice we observed this was not always the case.

One area of the premises had a strong odour of urine, from the seats there. We saw only 1 staff member wash their hands before assisting with meals and people were not assisted with hand hygiene prior to their meal. Not all staff wore tabards when serving meals and no staff wore gloves when serving and assisting people with their meals.

Regular environment audits ensured oversight of the premises in terms of maintenance and IPC.

Most people were happy with how their medicines were administered, however 2 people who self-administered their medicines were less positive. They felt staff became unnecessarily involved in suggesting changes to medicines and did not feel staff counting their medicines was necessary.

Staff did not raise concerns about medicines. They used an electronic system which linked with their eCare system. Staff did not need to deal with the issues the management team experienced with the system. The management team acknowledged there were inaccuracies in medicine counts and the amount the system had on record and listened to our comments on the current medicines practice.

The registered manager and deputy manager both had some oversight of medicines. However, there needed to be more clarity and more in-depth audits as we noted areas where information did not tally correctly that had not been picked up in existing audits. There had also been problems with the Wi-Fi signal in the service, in part due to the coverage but also due to a person frequently unplugging it. This meant the system may not always be fully synced and therefore potentially inaccurate. We noted incidents of incomplete records. For example, a person who was in hospital, 11 of their medicine’s records reflected this while 6 more had been left blank. We saw evidence of medicines not being given as prescribed. Two records reflected medicines that had been prescribed to be taken multiple time daily frequently omitted. A person prescribed regular paracetamol did not have a lunchtime dose for weeks which was recorded as ‘D1 – too early’ on 25 occasions, the 16:00 dose was also too early on 2 occasions. Lactulose was also recorded as ‘D1 – too early’ on 25 occasions when prescribed to be taken 3 times daily. Another record showed there was no stock of paracetamol on 5 February 2024, however later that day and on 4 occasions the following day different reasons were given for omitting the dose such as ‘too early’ or ‘medicine not required’. Additional stock of paracetamol was not added to the system until 7 February 2024. The record was inaccurate, and we are not assured the person would have had effective pain management because of the omission of their regularly prescribed paracetamol. Other records had inaccuracies in medicines quantities and there were multiple records of medicines not given as prescribed. None of the issues we found with medicines had been noted by the management team during any audits.