This inspection took place on 10 December 2018. The inspection was unannounced, which meant that the staff and provider did not know we would be visiting.

Evergreen Court is a purpose-built care home located in central Middlesbrough. It is a single-story building providing care and accommodation for up to 17 people assessed as requiring residential care. This includes support for people living with a dementia type illness.

Evergreen Court is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

At time of our inspection there were 15 people living at Evergreen Court.

There was a registered manager in post. 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.

At our previous inspection in February 2017 the service was rated as good. At this inspection the service was rated requires improvement.

At this inspection we found some issues with medicine management. For example, applications of creams to people were not recorded and out of date eye drops were being used. The provider took immediate action to address the issues we raised.

Recruitment practices helped ensure that suitable staff were employed however we did identify some gaps in records. Pre-employment checks were made to reduce the likelihood of the service employing staff who were unsuitable to work with vulnerable people.

Policies and procedures were in place to help staff protect people from harm, such as safeguarding and whistleblowing polices. Staff knew how to identify and report suspected abuse. The people we spoke with during this inspection told us they felt the service was safe.

Staff and most people told us staffing levels were sufficient. We received mixed feedback from families about staffing levels.

People’s care files contained the information staff needed to support them. Risks to people had been assessed and reviewed. Information was available for staff in how to best manage these risks. Environmental risk assessments were in place covering tasks undertaken by staff. Staff said that they were supported by the management team including through regular supervision meetings.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The policies and practices of the service helped to ensure that everyone was treated equally.

People had access to and the provider worked with a range of healthcare services such as GPs, occupational therapists and opticians. People’s nutritional needs were met.

The premises were clean and tidy. Staff knew how to help control the spread of infection. Equipment and building checks were undertaken to help ensure the environment was safe. Emergency contingency plans were in place.

People were supported by a regular team of staff who were knowledgeable about their likes, dislikes and preferences. Staff members were respectful and kind towards people. People’s privacy, dignity and independence were respected. Staff encouraged people to access a range of activities.

End of life care procedures were in place which recognised the needs of people and their relatives at this important time.

Feedback was sought to monitor and improve the service. Meetings for people, relatives and staff took place. Learning took place following reviews of accidents and incidents where themes and trends were addressed. A clear complaints policy and procedure was in place and followed by the provider.

Quality assurance systems w

This inspection took place on 10 February 2017 and was unannounced. This meant staff and the registered provider did not know that we would be visiting.

Evergreen Court is a bungalow and provides care for up to 17 people. 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. At the time of the inspection 16 people were using the service.

At the last inspection on 7 and 8 October 2015 we found improvements were required. We found that staff needed more training around the implementation of the Mental Capacity Act (MCA) 2005. Staff were not implementing the requirements of this legislation. More detailed information needed to be recorded in people’s care records and the systems for assessing and monitoring the service required strengthening.

We found the service in breach of regulations 9 (Person-centred care), 11(Need for Consent) and 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We rated the service as ‘Requires Improvement’ overall and three domains required improvement.

Following our last inspection the registered provider sent us information, in the form of an action plan, which detailed the action they would take to make improvements at the service.

At this inspection we found that the team had worked collaboratively to ensure all of the previous breaches of regulation were addressed.

People and relatives we spoke with told us they felt the service was safe. Risks to people using the service were assessed and plans put in place to reduce the chances of them occurring.

Safeguarding and whistleblowing procedures were in place to protect people from the types of abuse that can occur in care settings. People’s medicines were managed safely. There were enough staff deployed to keep people safe. The registered provider’s recruitment processes minimised the risk of unsuitable staff being employed.

Staff received mandatory training in a number of areas, which assisted them to support people effectively, and were supported with regular supervisions and appraisals. People’s rights under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) were protected.

People were supported to maintain a healthy diet and to access external professionals to monitor and promote their health.

People and their relatives spoke positively about the staff at the service, describing them as kind and caring. Staff treated people with dignity and respect. Staff knew the people they were supporting well, and throughout our inspection we saw staff having friendly and meaningful conversations with people. People were supported to be as independent as possible and had access to advocacy services where needed.

People and their relatives told us staff at the service provided personalised care. Care plans were person centred and regularly reviewed to ensure they reflected people’s current needs and preferences. People were supported to access activities they enjoyed. Procedures were in place to investigate and respond to complaints.

People and staff spoke positively about the registered manager, saying she supported them and included them in the running of the service. The registered manager and registered provider carried out a number of quality assurance checks to monitor and improve standards at the service. The registered manager had informed CQC of significant events in a timely way by submitting the required notifications. This meant we could check that appropriate action had been taken.

At the last inspection we found that medication administration records (MAR) for all of the people living at the home were not up to date. We found that consent forms and hospital transfer forms were incomplete and not signed.

At this inspection we went back to check the action staff had taken to ensure the records were being maintained appropriately. We looked at eight of the seventeen sets (47%) of care records and MAR charts.

We found that action had been taken to ensure MAR charts were up to date.

We found that people were protected from the risks of unsafe or inappropriate care and treatment because accurate records were maintained.

During the inspection we spoke with seven people, the manager, unit leader and three care staff. People told us what it was like to live at this home and described how they were treated by staff. People expressed satisfaction with the care and service that they received.

One person told us, “I like it here, it is smashing and the staff are really great. The staff look after you really well.”

We saw that staff were attentive and demonstrated a good knowledge and understanding of people’s needs. The atmosphere in the home was friendly and relaxed. During the visit we saw that staff interacted and communicated well with people.

We saw that people had their needs assessed and that care plans were in place. We saw that there were effective processes in place to ensure safe sharing of information with other providers.

The care and support was provided by suitably qualified, skilled and experienced staff. We found that the staff received appropriate training and had regular supervision and appraisals.

We found that medicines were administered safely.

We saw that records were not always completed accurately.

We found that systems were in place to monitor the quality of the service

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because the inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission inspector and joined by an Expert by Experience who has personal experience of using or caring for someone who uses this type of service and a practising professional.

To help us understand the experiences of people who used the service we carried out an observation called SOFI (Short Observational Framework for Inspection). This was a way of observing to capture the experiences of people who used the service.

During the inspection we spoke with six people who used the service and three relatives. We asked people if they were treated with dignity, respect and were given choice, comments made included:

"The staff are respectful, nice and we are confident that this is not just when we visit."

"I can have my breakfast when I want. It's no problem. I can have cornflakes and a cooked breakfast."

People confirmed that they were called by their preferred name and that they had been involved in discussions about their care and needs. People told us that they could make their own choice about when to get up when to go to bed, and how they wanted to spend their day. We were told that relatives and friends could visit at any time.

One person had requested a key to lock their bedroom door and the manager was in the processing of fulfilling this request.

We asked people about the food that was provided. People confirmed that that they were always offered a choice of food and drink at each meal time. People said that the portion sizes were good and that snacks were available throughout the day. Comments made included:

"Quite content with the food. There's something for everybody."

"Very good, can't fault, quite satisfied, happy."

During the inspection we asked people if they felt safe. One person said, "No worries we can leave her knowing he/she is safe." People confirmed that if they were worried or had any concerns they would speak with the manager.

We asked people if they thought there was enough staff on duty to meet people's needs and to support people at meal time. Everybody spoken with said that they were well supported by the staff team and that they were happy with the care and support that they received. Comments made included:

"It's very good here."

"There is always someone around to help if you need it."

We asked people if they knew about the written information kept about them which included their plan of care. One person spoken with was able to describe what a care plan was and said, "It is quite good." Another person said that they were aware that they had a plan of care but didn't feel the need to look at it.

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.