We inspected Evergreen on 4 and 5 December 2017. We previously carried out an inspection at Evergreen in June 2016 where we found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because we identified concerns in relation to the implementation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We also identified there was a lack of records to demonstrate actions taken in response to audit shortfalls and records were not consistently up to date and detailed. The service received an overall rating of ‘requires improvement’. The provider sent us an action plan and told us they would address these issues by November 2016.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had followed their action plan, and confirm that the service now met legal requirements. We found improvements had been made in the required areas and regulations had now been met. However, further time was required to allow time for changes to be fully embedded into practice. Therefore, the overall rating for Evergreen remains requires improvement.

Evergreen 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. Evergreen provides nursing and personal care and accommodates up to 16 people in one adapted building. At the time of the inspection there were 15 people living at the home.

A registered manager was in post, who was also the owner. 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 and associated Regulations about how the service is run.

Improvements had taken place since our last inspection in relation to the quality assurance system and records. However, these need time to be fully embedded into practice. People’s daily records and other charts were task based and did not fully reflect the support and engagement people needed. Some audits had not been completed and others did not identify the issues we found. Improvements had been made in relation to mental capacity, however, further work is required to ensure these are fully embedded into practice. Mental capacity assessments did not demonstrate how people who had fluctuating capacity were able to make decisions. These did not impact on people and we made a recommendation about this.

Improvements had been made in relation to mental capacity, however, further work is required to ensure these are fully embedded into practice. Mental capacity assessments did not demonstrate how people who had fluctuating capacity were able to make decisions.

The registered manager had identified areas where improvements were needed and work had started to address these. This included ensuring everybody was able to engage in meaningful activities and the completion of cream charts.

People were supported by staff who were kind and caring. They knew people well and had a good understanding of people’s individual needs and choices. They could tell us about people’s personal histories including their spiritual and cultural wishes. People were involved in the planning of their care and offered choices in relation to their care and treatment. Their privacy and dignity were respected and their independence was promoted.

Staff understood their responsibilities in relation to protecting people from harm and abuse. They told us what actions they would take if they believed people were at risk of abuse or discrimination.

Risks to people were identified, appropriately assessed and action taken to keep people safe. Systems were in place to ensure

This inspection took place on 13 and 14 June 2016. This was an unannounced inspection.

This location is registered to provide residential and nursing care for up to 16 people. People who used the service were older adults with personal care and nursing needs. At the time of the inspection, fourteen people lived at the service.

The service had a registered manager. 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.

Staff had completed training in safeguarding people from possible abuse. However, not all staff could explain what processes they needed to follow to keep people safe. We have made a recommendation about this.

The provider had not put in place full records to demonstrate safe recruitment practices. We have made a recommendation about this.

The provider had not routinely recorded that they reviewed people’s care plans and risk assessments regularly with people's involvement. The provider had not consistently recorded people’s views and wishes as to how their care should be provided. We have made a recommendation about this.

The provider had completed induction and supervision to address staff training and development needs to ensure people received effective care. Records of staff supervision were not made available to demonstrate that staff development needs were met to ensure people received effective care. We have made a recommendation about this.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Applications to restrict people’s freedom had been submitted to the appropriate DoLS office. People’s mental capacity was not appropriately assessed about particular decisions. When necessary, appropriate meetings were not held to make decisions in people’s best interest, as per the requirements of the Mental Capacity Act 2005. There was no recorded evidence people’s relative’s involved in best interest decisions had lasting power of attorney in place. This is required to enable them to lawfully make health and welfare decisions on the person’s behalf. Staff training in mental capacity and DoLS was not effective. Staff were not able to identify how people were subject to DoLS and how to apply the principles of the MCA in practice.

The provider had not considered accessible ways to inform people about services available to them, to include advocacy. We have made a recommendation about this.

People’s care plans were not personalised in all cases to enable staff to meet people’s individual needs, goals and preferences. Some people were not fully satisfied with the activities available to them. We have made a recommendation about this.

The provider had consulted people to obtain their feedback to influence how the service was developed. However, there were no records of how the provider responded to people’s requests and suggestions.

The provider's quality assurance system did not identify service shortfalls we found during the inspection, to ensure service improvements were made.

Medicines were administered and recorded safely and correctly.

Fire safety measures were in place to ensure people would be safely evacuated in the event of a fire. The provider completed health and safety assessments to ensure the environment was safe for people.

There was sufficient staffing level to meet people’s assessed needs.

People consistently had access to appropriate health professionals to effectively meet their health needs. People’s care and treatment was routinely reviewed with the involvement of relevant health care professionals to ensure their health, safety and welfare.

The service supported people to have meals that were in sufficient quantity, well balanc

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People had been cared for in an environment that was safe, clean and hygienic. Equipment at the home had been well maintained and serviced regularly. There were enough staff on duty with the appropriate skills and experience to meet the needs of the people living at the home. There were arrangements for senior staff including the manager to be on call out of hours. This was to provide support for staff in case of emergencies.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well. One person told us. "The staff are very helpful, and they make sure I don’t have anything to worry about”. Staff had received training to meet the needs of the people living at the home.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. One person told us “The staff care for me how I want them to; the care and attention the staff give to each person is great". A visitor told us "The staff are always checking on residents to make sure they are ok”.

Is the service responsive?

People’s needs had been assessed before they moved into the home. People told us that staff discussed any changes to do with their care with them regularly, and that staff were approachable if there were any issues of concern. Records confirmed people’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided that met their wishes. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives. A visitor told us “Staff are quick to respond if people need help”.

Is the service well-led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. People and visitors told us they were asked for their feedback on the service they received and that they had also filled in a quality survey. They confirmed they had been listened to and as a result of the survey, changes to the menu had been made. Staff told us they were clear about their roles and responsibilities. They said the management had consulted with them before implementing changes to the management of the home and their views had been taken into consideration.

There were 15 people living at the home on the day of our inspection. The home had one vacancy.

We spoke to seven people who spoke positively about the home and its staff. One person told us, “I am very comfortable here, looked after really well.”

We spoke to three staff in addition to the manager. We looked at three staff files and saw that the home had effective recruitment procedures. One staff member told us, “I have worked here a long time, it is a great place to work.”

We looked at three care plans and saw that they reflected the care that was provided to people.

We found the home was suitable for the people it accommodated. It was tidy and no unpleasant odours were detected. The home had systems in place to ensure maintenance was completed in a timely manner.

The home had an effective complaints procedure.

We looked at all areas of the home and found it to be clean and tidy. We spoke to people who lived at the home, however their feedback did not relate to this standard. One resident we spoke with told us they were happy living at the home. We spoke with three staff who all had a good understanding of infection control policies and procedures and were seen to use these appropriately.

During our inspection we spoke with two staff members and the registered manager. We talked with four people who used the service and one visiting relative. Everyone we spoke with who used the service told us they were happy to live at Evergreen. We undertook a tour of the home and saw the living areas and people’s bedrooms where they felt comfortable for us to see them. We looked at four care plans.

People told us staff treated them with dignity and respect and asked permission before carrying out personal care. The staff we spoke with were knowledgeable about people’s needs and what support they required. One relative told us, “I always see staff knocking on doors before entering. We’ve not experienced any problems at all.”

We found the home to be clean, tidy and well decorated. We also looked at the processes in place to ensure cleanliness and infection control. Whilst the home was clean, we found processes that ensured the control of infection were not fully established.

We found people were treated with respect at Evergreen, and people’s opinions were taken into account. Care plans had been written in a way that ensured people’s safety and contained care information.