Eversleigh Care Centre

Updated 30 September 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

The inspection was conducted by 2 inspectors, a specialist nurse advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Eversleigh Care Centre 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. Eversleigh Care Centre is a care home with 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 a manager in post, who planned to register.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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 10 people who used the service and 3 visitors about their experience of the care provided. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We also spoke with 8 staff, including the manager, deputy manager, operations manager, care staff and nurses and the nominated individual. We looked at a range of records including staff recruitment files, policies and minutes of meetings.

Updated 30 September 2023

About 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.