Eversleigh Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The provider was in breach of the legal regulations relating to good governance.

This service scored 54 (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 shared vision, strategy and culture. This was not always based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff told us the culture of the home was to focus on the needs of the people they cared for, and to work across teams so people would receive the care they wanted, but this was not always reflected in staff practice. There had been several changes to senior staff leading the home on a daily basis since our last inspection, including changes in home managers and registered managers.In addition, the registered manager split their time between Eversleigh Nursing Home and another of the provider’s services. There was a lack of ownership of the current concerns we identified and shared with the registered manager and limited ideas on how to resolve these issues, so they did not happen again in the future. The registered manager explained the challenges of refurbishing a listed building, but we found at the time of our inspection there had been limited consideration to managing existing or emerging risks. The lack of proactive management and direction had potential to expose people to unnecessary risks.

Not all leaders or the provider had the skills or knowledge to lead effectively, or they did not always do so promptly to ensure safe, quality care.

Staff told us they were able to gain advice from senior staff about the best way to care for people and said senior staff were visible in the home. However, there were mixed views from people and relatives about who led the home and how effectively this was done. Some people and relatives knew who the registered manager was, whilst other people and relatives were not sure who they would need to go to if they wished to talk with managers. Some relatives told us aspects of their family members care and the maintenance of the premises was not always managed effectively. Relatives told us there was a lack of regular, meaningful updates from the leaders at the home and communication regarding their family member’s care was not always effective. However, other people and relatives felt the home was run well. One relative said, “I felt the home was a positive choice, generally I’m happy with the care here.”

Senior staff were not always knowledgeable about issues and priorities which effected the quality and safety of the home. These included in relation to fire safety, medicines management and challenges with the environment. There was a lack of ownership, knowledge and insight regarding these areas by leaders. We could not be confident senior staff understood how the lack ownership may impact the quality of service and people’s safety.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they were able to raise any concerns at staff meetings or through direct discussion with senior staff. Staff knew how to escalate these to the provider or other organisations, should this be required. Staff told us they had not needed to raise any whistle-blowing concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff said they were treated fairly and gave us examples showing how they were encouraged to celebrate their own cultures to benefit people living at the home. For example, by chatting with people living at the home about their shared culture, experiences and languages. Staff were confident if they raised any concerns about how their equality needs were met, these would be appropriately responded to. Where staff wanted flexible work patterns, because of their own protected characteristics, this was supported by senior staff.

The provider did not always have clear systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes. Governance systems did not always work well or provide the registered manager and provider with the information they needed to be assured people were receiving safe, quality care.

At this inspection we saw some audits and actions had been taken, however some issues we identified were not known by the provider and registered manager. In addition, where the provider had identified improvements to be made, prompt action was not always taken to address these.

Where the provider was confident of safety and quality of people’s care through their checks, for example in medicine management and environmental risks, we found improvements were still needed. Quality checks when delegated to others had not identified some issues and the registered manager was not always aware of what was and what was not checked as part of those processes. Where checks had been delegated to senior staff, there was no managerial oversight to ensure those audits had driven improved practice. For example, we found concerns with some medicine storage and application of pain patch medicines. Despite these issues, the provider’s medicines audit scored 96% for June 2025 and 85% in July 2025.

Improvements to fire safety were still required. A fire authority visit in April 2025 identified a number of fire doors required action to make them safe in the event of an emergency. Theses had not been actioned at the time of our inspection. In addition, we found several fire doors still required adjustment to ensure they were effective in the event of a fire. These issues identified by us had not been known by the registered manager. Further, 1 fire door required replacement, but prompt action had not been taken to replace this. The provider’s fire risk assessment action plan dated 21 March 2024 identified weekly fire alarm tests were not always being undertaken. This had been annotated to say it had been actioned but was again identified in the provider’s fire risk assessment action plan dated 03 April 2025. The concerns around weekly fire alarm tests had still not been fully resolved by the time of our inspection.

Governance systems in place had not ensured there was sufficient provider oversight of the quality of checks undertaken by senior staff. This included in relation to medicines management where errors had not fully been investigated. In addition, checks of staff practice when interacting with people needed to be further embedded. A provider representative advised us about the work and improvements they planned to introduce to medicines management as a result of our inspection findings.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and usually collaborated for improvement, but some people and relatives told us they were not always treated as partners in care. Some relatives highlighted there was a lack of clarity about how involved they could be in their family member’s care, and limited opportunities to provide informal feedback. However, other people and relatives said they were more positive about these areas.

Staff told us strategic links had been developed with other local health and social care organisations, for the benefit of people living at the home. We saw evidence people received support from external health services. These included the local GP, tissue viability specialists and speech and language therapy. However, further development of strategic links with pharmacists and medicines manufacturers was required, so staff were fully supported to make decisions when considering the best way to store and administer people’s medicines. Further consideration needed to be taken by staff, to ensure diagnosis specific best practice was followed. For example, in relation to annual health checks and communication plans. This would help to promote a seamless care experience for people across services.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

This inspection has identified a lack of oversight and consideration in identifying new or emerging risks. Fire safety checks had been completed, but we found several fire doors did not work as intended. We found where the environmental challenges of an older building were known, ineffective measures to keep people safe had been implemented. For example, there had been a delay in replacing a fire door, where this was required to maintain people’s safety. Learning and improvement through the provider’s own audits and checks was not always effective. Senior staff did not always acknowledge their accountability to promptly improve the quality and safety of the home. The provider’s systems needed to become more embedded and day-to-day practice developed further, to identify potential concerns through their own audits and checks. This approach would support a learning and improvement approach.

However, we found there was some evidence of learning taken in relation to clinical concerns and some learning had been shared relating to inspections at the provider’s other locations. The registered manager told us about other ways they were planning to improve the learning at the home. This included considering the introduction of some quality assurance awards to continue to maintain others. In addition, the registered manager told us they planned to reintroduce employee of the month recognition schemes and to reintroduce further support for people, so they were less at risk of social isolation.