The Evergreens Lodge

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We reviewed 8 Quality Statements in this key question. We found shortfalls in the governance and oversight of some aspects of the service. However, learning was taken from accidents, incidents and near misses and the registered manager had worked hard to improve on previously poor relationship with healthcare professionals.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider was working towards improving their service and relatives reported they were kept fully informed of life in the service. The registered manager sent a monthly newsletter to relatives and people to ensure they felt part of life at the service. The registered manager also ensured regular resident’s meetings were held to try to engage more fully with people, however, there was a reluctance to attend these meetings from some people using the service as the registered manager delegated chairing the meetings and did not attend. Quality assurance surveys were regularly issued to people so satisfaction levels could be monitored. One person told us they felt uninformed and disinclined to complete QA surveys due to feeling uncomfortable about the comments they would have to write if they did complete them.

Regular newsletters kept people and relatives informed about events in the service. Priority was given for staff to learn more about the Gold Standard Framework as the provider was trying for accreditation. Team meetings and supervisions reinforced expectations of practice alongside updating staff members.

Feedback from staff about the leadership team was all positive, staff felt supported and described leaders who were approachable and willing to help staff. Staff also told us the management team stepped in and helped with care tasks should there be a shortage of staff.

The provider enabled the management team to train and become qualified in relevant areas. For example, the registered manager would be undertaking a human resources qualification to enhance their practice in this area. The management team took onboard findings from previous Care Quality Commission inspections and external assessments and had endeavoured to meet all the identified shortfalls. When we inspected, these had not yet been fully completed. We queried why a person was receiving too much fluid daily, they were on a very restricted fluid intake due to a serious health condition. We were provided with fluid records for the person for the same dates of the records we had already reviewed. The records reflected different information and indicated the person had in fact been given the current amount of fluids. Due to the disparity in the 2 records, we are not assured this person was receiving care in line with instructions from healthcare professionals.

Staff were positive about going to the management team, particularly the registered manager, if they had concerns, needed advice or just needed a chat. They believed the registered manager would listen and act on their concerns should they raise anything.

Staff were able to provide feedback through a survey system and all had expressed they could speak directly to the registered manager. The provider had a whistleblowing policy available to all staff, a copy of which was in the staff room.

Staff told us they had never experienced any discrimination when at The Evergreens Lodge. The registered manager had also begun to include people living at The Evergreens Lodge in the staff interview process to ensure those recruited were approved by the people there and to ensure they felt included in the process.

There was an equality and diversity policy detailing the provider and staff teams responsibilities under the underpinning legislation. In addition, there was a second part to the policy used by staff as a guide to give a basic overview of what to consider when providing care to people of different faiths and ethnicities.

There was a range of audits in place and in addition, the provider had engaged an independent company to complete a mock inspection audit. This audit had identified a number of actions to be taken to improve the service including introducing a reflective learning process, adding continence product details and links to good practice guidance to care plans. The audit was positive and identified good practice within the service.

We discussed the medicines audits with the management team as we had found these did not match our findings. This potentially impacted on people as there were disparities between records, what had taken place and what had been recorded due to staff using incorrect codes. This had not been noted in any of the audits completed by the registered manager. We were also concerned the incorrect weight settings on air mattresses had not been noted in any audits The registered manager had established audits and had some oversight of the service. We saw a range of audits including actions to be carried out to improve the service. Some actions had been completed, for example an action following a fall was to continue to monitor. Other actions such as updating care plans after they were audited would be completed at the next care plan review.

We did not receive feedback in this particular area from staff or leaders.

There were partnerships in place, district nurses attended the service as did GP’s. They provided advice and guidance along with treatment for people. Feedback we received included, "There are patients who needs are more than residential, they need nursing care but this is something the home no longer provide so that is still…you know, complex dementia and high health needs not always met but certainly better than say six months ago." The provider contacted GPs on behalf of people and there were regular ward rounds from 2 surgeries.

We were not assured referrals for healthcare support were always 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 the person had 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 and unwell as they had.

Staff told us incidents had been discussed following events. In serious situations they may be called aside for an immediate discussion, speak about things in team meetings or in 1-1 supervision sessions with line managers.

Audits completed identified actions. These were shared with the staff team, if appropriate, through meetings and handovers. We have noted some shortfalls in audits that need to be improved. The provider was working towards achieving accreditation to an end-of-life pathway.