Everdale Grange

On this page

• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. However, we discussed a safeguarding allegation that had not been reported to external agencies or CQC as required. Whilst the management team had investigated, this should have been reported externally. This allegation is currently being reviewed by the police. The management team apologised and accepted this had been a mistake and as a result they have reviewed their practice, systems and processes to ensure full and open transparency.

Lessons were learnt to continually identify and embed good practice. We saw examples of lessons learnt and the actions taken by the management team to make improvements. Staff meeting records confirmed examples of shared learning and outcomes.

Action was taken to reduce the risk of falls such as increased monitoring and use of assistive technology such as sensor mats. Records were completed for every accident and incident and this information was analysed so that changes could be made to reduce further risk. For example, post fall analyses included the consideration of factors such as prescribed medicines, psychological wellbeing, staffing numbers, any equipment involved and the environment. Two people identified as being at high risk of falls had good outcomes from this intervention because they not had any falls for a number of months. All staff had completed falls reduction training.

People and relatives spoke positively about the care and treatment provided and raised no concerns. Staff told us about the communication systems in place to share information and areas for actions and improvements. A staff member said, “I really enjoy my work, I feel that I'm good at caring. The management are good, they are approachable, you're freely able to go and raise anything. If I had any concerns I would go to the head of care, but I know I can go direct to the management team.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People had access to the healthcare they required. The GP visited the service twice a week to carry out reviews. Staff recognised people’s changing health needs and referred people appropriately. Staff followed advice provided by healthcare professionals.

The provider had systems and processes for sharing information with external healthcare professionals such as ambulance and hospital staff. This included sharing information with other care provider’s if people transitioned to other care services.

Feedback from people and relatives confirmed the provider’s pre-assessment and transition process was detailed and supportive in ensuring consistent and safe care. A relative told us about their loved ones recent admission. They said, “They (staff completing the assessment) wanted to know relation’s likes, doesn’t like. What their needs are. What they did for a job.”

Staff told us how they had access to electronic care records and guidance was detailed and kept up to date. Staff had daily meetings where people’s care and treatment needs were discussed, including new admissions and discharges.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider had improved their systems and processes to ensure they shared concerns quickly and appropriately with external agencies.

At the time of this assessment, the provider was working with the local authority and police in investigating some safeguarding incidents. This included the provider having completed internal investigations and taking improvement actions such as providing staff with refresher training.



Staff understood their responsibilities to protect people from abuse and harm. Staff had received training and knew how to recognise the signs of abuse and how to report. Staff were confident their managers would take any concern seriously. Information about reporting abuse was available to people and visitors. A staff member said, “Safeguarding means protecting residents from harm, neglect, or abuse. I must report any concerns immediately to the management. I also ensure that residents are treated with dignity and respect at all times.”

Where people required any deprivation of liberty in order to keep them safe, the provider had applied for lawful authorisation from the local authority. Information about deprivation of liberty safeguards was clearly recorded in people’s care records including any conditions that applied.



People and relatives told us they had no concerns about safety.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care that was safe, supportive and enabled people to do the things that mattered to them.

Risks associated with people’s individual care and treatment needs had been assessed and were regularly reviewed. This included the risk of developing pressure sores, swallowing difficulties and falls. Where risks were identified, a care plan and risk assessment were developed so staff knew what action to take to reduce any risk of harm.

Staff were knowledgeable about people’s identified risks. Records showed where people required positional changes to prevent pressure sores, these were accurate and up to date. Where people were at risk of falls, assistive technology was used such as sensor mats to alert staff when people were moving independently. Where people were at risk of choking, speech and language therapists had completed an assessment and recommendations made about specific diets had been implemented.

Where people displayed emotional distress, positive behaviour care plans were in place, so staff knew what to do to reduce distress and provide reassurance. Staff had consulted with community mental health teams and were following their advice. We were aware the provider was working with the local authority positive behavioural support team, this included reviewing the provider’s policies and procedures in how staff supported people living with dementia whose emotional distress could impact their behaviour.

We saw a staff member supporting a person who was emotionally distressed, and they managed this in a sensitive way. Staff supported the person to express their needs and provided effective reassurance while maintaining safety.

People and relatives told us how they were involved in discussions and decisions about how risks were managed. A relative said, “Everything that happens they [staff] ring me. So, I can come and be part of any meetings.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety audits and checks were completed regularly on the environment, premises and equipment. The management team also completed daily walk arounds to check the environment was safe. Fire risks were assessed, and staff had completed fire safety training and participated in regular fire drills. Personal emergency evacuation plans had been completed and these informed staff and emergency services of how to support people to safely evacuate the building. Systems and processes were in place to regularly test the water supply from the risk of legionella a water bacteria that can cause serious ill health.

The provider had a refurbishment plan that confirmed improvements planned for the environment.

We observed equipment used had been serviced and was in good working order. The environment, including layout of the building, supported people’s safety.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

The provider used a dependency tool to assess people’s individual care and treatment needs and to determine safe staffing levels. Some people had additional one to one care and support in order to keep them safe. We observed staff supported people in the least restrictive way, allowing them space while also being available as soon as any support was required. A relative of 1 person who received additional staff support, told us staff were always available and knew how to meet their relations needs.

The management team told us how staffing levels were reviewed at least weekly to ensure safe staffing levels were maintained at all times. Staff were recruited in a safe way. Appropriate checks were carried out before employment was offered so that as far as possible, only suitable staff with the right skills and experience were employed. Induction training was provided to new staff and this included ‘shadowing’ experienced staff. Staff then went on to complete the care certificate which is a nationally recognised induction training to ensure they were aware of expected standards within the sector.

Staff completed mandatory training and additional training the provider had identified as required. All staff completed a range of staff competencies, including additional clinical care tasks by nurses and healthcare staff. Staff training data confirmed good compliance. Staff confirmed they received the training and support they required, and this included ‘supervision’ with their line managers so performance and any training or development needs could be discussed and planned. A staff member said, “I get training, supervision, and help from my team. If I ever need support, my manager is always there to ask something.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All areas of the service were visibly clean. Staff had access to personal protective equipment and knew how to safely manage waste. There were enough domestic staff on duty who followed cleaning schedules in line with best practice guidance.

Staff knew how to manage any infectious outbreaks and knew not to attend work if they were unwell. A member of the domestic team said, “Managers take infection control and cleanliness very seriously and carry out checks to make sure the service is cleaned to a good standard.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Systems were in place for staff to safely administer and store medicines. Records we checked showed people were having their regular medicines administered safely and on time. Additional monitoring for medicines was carried out where necessary to ensure that they were safe and effective.

Staff were supported by person centred guidance to support people with their medicines. Some records we looked at relating to medicines required some improvements, which was feedback to the provider after inspection, however this had not impacted on people’s care. Staff had had completed medicines training and had their competency regularly assessed.

Staff understood how to use tools to assess pain for people who were unable to communicate whether they were in pain and required pain relief. Best interests’ decision meetings had taken place for people who had had their medicines administered covertly (this means without their consent and disguised in food or drink). Pharmaceutical advice was in place to ensure that medicines were administered safely. We saw good practice systems in place for the safe management of medicines pain management patches. People were supported to have their medicines reviewed regularly by healthcare professionals.