20 June 2023
During an inspection looking at part of the service
Eversleigh Care Centre is a residential care home providing personal and nursing care to up to 84 people. The service provides support to older people, some of whom are living with dementia, or have a physical disability. At the time of our inspection there were 49 people using the service.
Eversleigh Care Centre accommodates people in 3 separate units, each of which has separate adapted facilities. Only 2 units were in use at the time of the inspection.
People’s experience of using this service and what we found
Systems and processes in place to monitor people’s care delivery were not effective in ensuring actions were taken when there were gaps in records.
People did not always have their medicines administration documented. People’s care records did not always show how and when their planned care had been delivered.
Staff understood how to support people to manage risks to their safety and could recognise any signs of abuse and taken action to protect people.
Staff were recruited safely and there were enough staff to meet people’s needs. The service was clean, hygienic and infection prevention control procedures were followed. When incidents occurred, these were reviewed, and actions taken to prevent them from happening again.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People were supported to be engaged in the home. There was support for staff in their role and regular updates about learning when things went wrong. There were relationships with other health professionals where required to support people with their care needs. The provider had systems in place to ensure they met their responsibilities for duty of candour.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (6 April 2023).
The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection we found improvements had been made and the provider was no longer in breach of some regulations, but others remained in breach.
Why we inspected
We carried out an unannounced focussed inspection of this service on 7 February 2023. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, staffing and governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Eversleigh Care Centre on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to governance arrangements at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will meet with the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.