Background to this inspection
Updated
26 May 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
Inspection team
This inspection was undertaken by one inspector.
Service and service type
Eversfield House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Eversfield House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was not a registered manager in post. A new manager was in post who had been working with the service for 7 weeks. They had plans to apply to become the registered manager.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 6 people and 4 staff, including the manager, senior care worker and care workers. We reviewed 5 people’s care records and records relating to staffing and the management of the service. We undertook observations of the environment and observed interactions between people and staff.
Updated
26 May 2023
About the service
Eversfield House is a residential care home providing personal care to up to 24 people. The service provides support to older adults. At the time of our inspection there were 24 people using the service.
People’s experience of using this service and what we found
People were at risk of receiving unsafe care and support. There were insufficient care records that did not detail specific information about risks to people’s safety and how they were to be supported. We observed staff supporting people safely and they had good knowledge of people’s needs, but this information was not recorded.
The provider did not ensure the environment was always safe and people were protected from the risk of falling from height. Windows were not appropriately restricted and there were no barriers from the fire escape to prevent people from going onto part of the building with a flat roof.
Medicines were not managed safely. Staff did not maintain accurate records of administered medicines and staff were not observing people taking their medicines to ensure they were taken as prescribed. Medicines were dispensed into staff’s hands prior to being given to people, increasing the risk of contamination.
There were insufficient systems in place to provide adequate oversight of the quality of the service. Audits and checks on the quality of care had not been completed in the months before our inspection. There were no clear improvements plans in place to ensure timely action was taken to address any concerns identified.
Despite the concerns raised about the systems and processes in place, staff were knowledgeable about people’s needs and we observed them providing people with the level of support they required to ensure they had a good quality life, and they were supported in a safe way. Staff worked closely with the GP and staff from the local authority’s care home support team to ensure any concerns about people’s health or welfare was reviewed.
People enjoyed living at Eversfield House and told us they felt comfortable speaking with staff, and expressing their views and opinions. 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.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 16 June 2021).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
We undertook a focused inspection to review the key questions of safe and well-led only. 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 changed from good to requires improvement based on the findings of this inspection.
Enforcement
We have identified breaches in relation to safe care and treatment and good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.