The inspection took place on 28 September and 9 October 2018. The visit on 28 September was unannounced; the visit on the second day was announced as we required the registered manager to be in the office to assist with the inspection.

This was the first inspection of the service since they were registered on 7 August 2017. At this inspection we found evidence to support the rating of Requires Inspection.

There was a registered manager was 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.

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

Evington Grange accommodates up to 6 people in one adapted building.

The inspection was a first rating inspection.

The provider carried out some quality monitoring checks in the home supported by the registered manager and home’s staff. However, there were shortfalls in the training matrix, fire and evacuation system, the recruitment application form, statement of purpose and medicines system and competency of staff when administering medicines were also out of date.

The provider had a clear management structure within the home, which meant that the staff were aware who to contact out of hours if an emergency arose, or an equipment repair was necessary. Staff had access to the maintenance diary to manage any emergency repairs. The provider had developed opportunities for people to express their views about the service, however, not many of the current people living in the home had the chance to participate in the latest questionnaire. These included the views and suggestions from people who used the service.

We found that applications had been made to the local authority to legally deprive people of their liberty. The registered manager and care staff had been trained in the Mental Capacity Act (MCA) 2005. They were also aware where best interests meetings would be planned to ensure people’s treatment was in line with the MCA and Deprivation of Liberty Safeguards. People or where appropriate their representatives were asked for their written consent to care following their admission to the home.

Following their recruitment staff received on-going support and training for their job role. Staff were able to explain how they kept people safe from abuse and were aware of whistleblowing and what external assistance there was to follow up and report suspected abuse. Staff were subject to a thorough recruitment procedure that ensured staff were qualified and suitable to work at the home.

People were supported to continue with their chosen dietary and cultural needs. Staff supported people to undertake a range of activities that were tailored to people’s interests and needs. Staff had access to information and through this had developed a good understanding of people’s care and support needs. Care and support plans were updated to include changes to peoples care and treatment and people were involved in the review of their care and support plan. People were offered and attended routine health checks, with health professionals both in the home and externally.

People were able to maintain contact with family and friends and visitors were welcome without undue restrictions. We observed staff interacted positively with people throughout the inspection, people were offered choices and their decisions were respected.