Archived: Everley Residential Home

Updated 19 February 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. This inspection took place on 20 October 2014 and was unannounced.

The inspection was undertaken by two inspectors and an Expert by Experience, (ExE). An ExE is a person who has personal experience of using or caring for someone who uses this type of care service. The ExE had knowledge of the needs of older people and spent time with people and relatives to gather their views about life at the home.

As part of our inspection process we asked the provider to complete a provider information return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. Before our inspection, we reviewed the information we held about the service and the provider. This included notification’s received from the provider about deaths, accidents and safeguarding alerts. A notification is information about important events which the provider is required to send us by law.

We requested information about the service from Dudley Local Authority and NHS Commissioning Group. Both have responsibility for funding people who used the service and monitoring its quality. They did not share any concerns about the service.

We spoke with the 12 people who lived at the home, four relatives, the manager, four staff and the cook. Some people were not able to tell us about their care so we spent time observing them being supported by staff. We looked at the care records related to four people, and sampled accidents records, training records, menus, complaints, quality monitoring and audit information.

Updated 19 February 2015

This inspection took place on 20 October 2014 and was unannounced. The last inspection on 14 October 2013 identified that the provider was fully compliant with all of the regulations we looked at. Everley Residential Home provides accommodation and personal care for up to 16 people who may have needs due to old age, physical disability or dementia. At the time of our inspection 13 people lived at the home. A registered manager was employed at the service. 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 we spoke with understood that they had responsibility to take action to protect people from harm. They demonstrated awareness and recognition of abuse and systems were in place to guide them in reporting these. However, staff including senior staff lacked awareness of how to report issues to outside agencies in the absence of the manager.

People and their relatives consistently told us they were happy with the service provided and that staff understood their needs.

Staff understood how to manage the agitation of some people without the use of additional medication. Where specific precautions were needed to take medicines in a specific way, written details to support these practices were not always evident to guide staff to ensure people’s medicines were managed safely.

People were cared for by staff who knew them well and who they described as kind, caring, respectful and patient. We saw that staff respected and responded to people’s individual needs. However, people told us and we saw there was not enough staff to support them with recreational pastimes of their choice and opportunities for people with dementia were not fully apparent. We saw that there were some occasions where additional staff were needed to ensure they were able to respond to people’s behaviours that were causing alarm to others; a view shared by people and staff.

People’s needs were assessed and care plans were detailed to provide guidance to staff to meet people’s needs. People were supported to access health care services and so received effective care that was based around their individual needs.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) and The Mental Capacity Act 2005 (MCA) and report on what we find. The manager had undertaken training in this area to ensure she understood her role and responsibilities. However the provider had not followed the guidance where some people’s liberty had been restricted. No applications had been submitted to the supervisory body so that the decision to restrict somebody’s liberty is only made by people who had suitable authority to do so.

Risks to people’s health and wellbeing were well managed. They were supported to eat and drink well and had access to health professionals in a timely manner.

Staff were provided with training in order to develop the skills and knowledge to provide safe and appropriate care to people. Staff had access to regular support and supervision to ensure they could discuss their practice as well as their training needs. The provider had a rolling programme of training and we saw that refresher training was being booked.

The manager was open to managing people’s comments and complaints and people were confident these would be responded to. The views of people and their relatives had been regularly sought via meetings and surveys to obtain their feedback, and areas for improvement were being addressed.

The provider had a quality assurance process for monitoring and checking the quality of the service. Whilst some redecoration was evident to improve the premises, there were some environmental risks which had not been identified by the provider’s auditing and quality processes and could potentially compromise the safety of people. These related to harmful chemicals left unsecured, tools, rusted equipment and worn flooring.

We found a breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to the following; The requirements of DoLS. You can see what action we told the provider to take at the back of the full version of the report.