Eversleigh Nursing Home

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 requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The provider was in breach of the legal regulations relating tosafe care and treatment and premises and equipment.

This service scored 47 (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 did not always have a proactive and positive culture of safety. Staff did not always robustly investigate safety concerns. Lessons were not always learned to continually identify and embed good practice.

Discrepancies in the stocks of people’s medicines were identified by inspectors during the inspection. Staff told us they changed the total on the electronic medicines management system without any investigation to understand why there was a discrepancy. We also saw medicines audits recorded action for stock count discrepancies as ‘the system was changed’. This meant opportunities for maximising learning were not always taken. Reasons for stock discrepancies may include people receiving more or less medicines than prescribed. In addition, learning had not been consistently and promptly taken when feedback was provided by external consultants and specialists, including in relation to fire safety.

However, there were other occasions where learning was taken from incidents. For example, in relation to improvements identified in clinical care, which were discussed with staff and actions put in place to reduce the likelihood of similar events. This demonstrated an inconsistent approach to taking learning from incidents.

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.

One staff member told us they were easily and securely able to provide other health and social care providers with the information required when people transferred between services. The staff member said, “Our [information technology system] has a hospital admission kit. This provides information on [people’s] blood pressure, if they need any medicines, their diagnosis and their dietary needs.” The staff member also described how they would obtain information when people transferred to them from other health and social care settings, so their needs would continue to be met. Another staff member said where people had made a decision not to receive any medical intervention in the event of a cardiac event, this was known and was communicated appropriately. This helped to ensure people’s needs were identified and their wishes were promoted when they transferred between services.

The provider did not always work with people to understand what being safe meant to them and to achieve this.

We found there were some occasions where the provider had not taken prompt action where risks to people had been identified. For example, in relation to the premises. This placed people at risk of neglect.

However, relatives were positive about the arrangements in place to promote people’s safety. One relative told us they had raised a safeguarding concern with staff and said this had been promptly investigated to their satisfaction. Staff had worked with the relative and healthcare partners to agree and put in place a plan to mitigate future risks. The relative said, “[Staff] did a full investigation. They were very good about the incident.”

Staff knew how to identify potential safeguarding concerns, and which external organisations had responsibilities for promoting people’s safety, should this be required.

The provider did not always work well with people to understand and manage risks. Staff were not always provided with clear guidance to provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were mixed views from people and their relatives about how involved they were in decisions about people’s safety. One person told us, “[Staff] have never discussed safety with me.” A relative said, “I’ve never had a conversation about [person’s name] safety.” However, another relative told us, “We’ve had lots of conversations with [staff] to try and mitigate [person’s name] falls.”

Staff were not always provided with consistent guidance on how to manage people’s risks. For example, in 1 person’s care plan staff were told to check a specific area of their physical safety at 30 minute intervals. However, another area of their care plan said this should be done on an hourly basis. In addition, 1 person’s care plans did not provide staff with clear guidance on how to support a person who had risks in relation to choking. This was because 1 area of the person’s care plan said they required normal consistency of diet and fluids, whilst in another area of the care plan staff were informed the person required thickener.

The provider did not detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

One relative said, “I would give 4 out of 10 for the building and 9 out of 10 for [person’s name] care.” The relative told us their family member had changed rooms, following a leak from the ceiling.

At our last inspection we found improvements were required with window restrictors, people’s personal emergency evacuation plans and equipment to keep people safe in bed. At this inspection we found some improvement in these areas. However, we continued to find there was limited evidence environmental risks were managed and responded to in an effective and safe way. The registered manager said they completed daily walk arounds, but we found a number of issues within the environment which had not been identified by them. Unmanaged risks, such as some ineffective fire door checks, meant risks people may be harmed or injured had not been identified. For example, we found fire doors to people’s bedrooms closed too quickly, while 1 person’s bedroom fire door did not close securely into the door jamb which increased the risks of a fire spreading. In April 2025, the fire authority found concerns related to fire doors. The required improvements had not been addressed by the provider. In addition, risks to people were increased because fire alarm tests were not always regularly undertaken. The registered manager told us of their plans to upgrade and refurbish the home, but was not able to provide us with a schedule of works at the time of our inspection. There had been limited action taken to manage these risks at the time of the inspection. This put people at risk of harm.

Areas of the building which needed to be secured to meet people’s safety needs were not always appropriately secured. An internal door on the first floor identified as ‘no entry’ provided access to an external wooden platform which was at height. The registered manager confirmed the door should have been secured because of movement in the wooden gantry between the 2 external areas of the building. There was risk of a fall from height because this area of the home was not secured. Inspectors asked for this to be secured with immediate effect.

Other risks were present. For example, in 1 communal bathroom we found a hatch at floor height which had no lock. This provided access to a void into a loft space. This hatch was large enough for a person to get through. We could not be confident the loft area would hold a person’s weight, or if staff would notice if a person had entered this area. In addition, we found people’s wardrobes were not attached to the wall in a number of bedrooms. We also found some people’s medicinal creams were not appropriately stored and may cause harm to people if ingested.Further, the basement area of the home was unlocked. Trip hazards were observed on the floor leading to the gas isolation point. Ceiling paper was also hanging down from the ceilings. None of these potential risks had been identified and rectified by staff. This had potential to put people at unnecessary risk.

However, relatives told us appropriate equipment such as sensor mats were in place to help to meet their family member’s safety needs. Checking of services such as electrical installation and gas safety had been undertaken by external contractors.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective development. Staffing deployment or levels did not always meet people’s individual needs.

There were mixed views from people and relatives regarding if there were enough staff to care for them. One person said, “The staff are okay the levels seem alright.” A relative told us, “Staff levels seem alright.” However, several people and relatives told us there were delays when they wanted support from staff. One relative said, “I have asked questions about staffing levels on this floor, I feel on occasions it’s a bit light. I would also question the supervision [of staff] at weekends, I can’t find staff and they are always running around.” Another relative told us they were not confident there were sufficient staff to meet their family member’s needs when these had increased. The relative told us senior staff had acknowledged there had been shortages of staff when their family member required extra support.

Staff we spoke with said there were enough staff to meet people’s needs and gave us examples showing how staffing levels had been increased as people’s needs changed. The registered manager told us they used a dependency tool to determine staffing levels and said they often exceeded the number of hours required. However, we saw staff were busy and heard call bells ringing for extended periods of time during the inspection.

Some people and relatives were positive about the skills staff had to help them, but others highlighted there was variance in the knowledge and experience of staff. Staff told us they were supported to develop their skills through training organised by the provider. One staff member said, “[Senior staff] are particular about your training.” A senior staff member said they were supported to keep their professional qualifications up to date. However, the provider had identified some staff had not completed the training required of them. For example, in relation to dignity in care, moving and handling and fire safety. This remained a concern at the time of our inspection. In addition, we saw there were times when staff did not take practical action to put their training into practice and there was limited interaction with people from staff.

Systems were in place to check the suitability of staff before they commenced employment. These included obtaining references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. Staff were supported to provide good care to people through access to senior staff and on-going supervisions. However, checks on staff practice in relation to maximising opportunities to interact with people needed to be further embedded.

The provider had not always assessed and managed the risk of infection. The provider detected and controlled some risks and understood they needed to communicate concerns with appropriate agencies promptly.

There was a lack of effective maintenance of the premises which increased the risk of the spread of infection. This included cracking to paint surfaces in 1 person’s bedroom and shared bathrooms, 1 of which had a stained floor and unsealed, porous surfaces. Broken and porous surfaces are difficult to clean effectively. Some skirting boards, door frames and doors were not maintained and were in need of repair. This made it difficult to keep clean and minimise cross infection risks. Specific rooms designed to launder soiled items were not always well maintained. This created potential issues to reducing the risks of cross contamination. In addition, we saw food debris on the floor in 1 person’s bedroom. These factors increased the risk of the spread of infection.

However, relatives told us their family member’s rooms were regularly cleaned. One relative said, “[Person’s name] room is kept very clean. I have noticed urine smells from their carpet. They shampooed it yesterday.” Another relative said, “I’m happy with the room cleanliness, they do it regularly.”

We saw some positive practices to minimise cross infection. Handwashing signage was displayed in some toilets and bathroom areas and personal protective equipment (PPE) stations were near bathrooms and were stocked. Staff were seen to use the appropriate PPE at the required times.

The provider did not always make sure that medicines and treatments were safe and met people’s needs. We could not be confident people received their medicines safely and as prescribed.

We checked if people’s medicines were stored safely and found daily room and refrigerator checks were made and were within safe range. However, we saw 1 person’s eye drops were stored on their side. This was not in line with the manufacturer’s instructions to store these upright. We also found some paraffin based topical creams were stored in a linen cupboard. The provider could not therefore be confident these creams had not exceeded a storage temperature of 25 degrees Celsius. Storage at temperatures exceeding this level may degrade the cream, reducing its quality and effectiveness because high temperatures can break down the active ingredients.In addition, we found some medicines were stored in a fridge when they may not be required to. Senior staff could not provide a rationale for storing this medicine in the fridge, and there was no risk assessment undertaken to consider the safety of doing this. There was no audit trail to confirm staff had contacted the manufacturer or a pharmacist to discuss the storage of the person’s medicines and confirm this was safe and appropriate.

Senior staff were not confident or aware of how some medicines needed to be administered to people to ensure their health and well-being was maintained. We found some patch medicines were not applied correctly to the skin, which could cause skin irritations, or for the medicine not to be effective. Staff who administered these medicines were not aware they had to rotate where the patch medicines were applied, to reduce risks to people.

Staff did not always have the knowledge required to safely administer people’s specific medicines. For example, 1 person required eye drops to be administered. The manufacturer’s guidelines said ‘do not exceed 5 days dose.’ We checked the person’s medication administration form and found staff administered the eye drops from 05 August 2025 to 19 August 2025, a period of 14 consecutive days. Staff told us it was safe to do so, but there was no evidence staff had confirmed the administration continuation with the healthcare professional who had prescribed the medicine.

Processes to ensure people received their medicines safely were not working well. We found some medicines stocks held did not agree with people’s medicines administration records. We could not therefore be assured people had received the correct amounts of medicines they needed to remain well. The registered manager told us they were not involved in medicines management or checks. Senior staff said they were not aware of the issues we found but agreed to rectify them with staff.

In addition, some information technologies used to administer people’s medicines did not always support the safe delivery of care. For example, staff told us their electronic handheld medicines devices only contained a limited history of medicines administered to people. Staff were able to obtain a more detailed history of the medicines administered to people by using a computer, but staff told us this was not ideal if they were not in the vicinity of the computer. This was likely to increase risks to people.

We told the registered manager and senior staff about our concerns. They provided assurances they would review the systems in place to manage people’s medicines without delay.