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Everley Residential Home Requires improvement


Inspection carried out on 20 June 2019

During a routine inspection

About the service

Everley Residential Home is a residential care home providing personal care and accommodation to people aged 65 and over who may also be living with dementia. The care home is registered to provide support to 16 people in one adapted building, at the time of inspection 15 people lived at the home.

People’s experience of using this service and what we found

The manager lacked oversight and had no access to action plans and finances. Systems were not effective for monitoring the quality and safety of the services provided. There was good involvement with community professionals. Staff knew how to raise concerns about poor staff practice.

Concerns were identified with infection control, environmental health and lack of maintenance. People received medicines as required however stocks did not always balance meaning medicines were not always safely managed. Improvements were required with recruitment checks and assessment of staffing levels. People told us they felt safe and staff knew people well.

Peoples social needs were not always met, and activities were lacking. The number of complaints were recorded but the detail of what the complaint was, was not always documented. People felt able to talk to staff who would listen to them. End of life preferences were recorded for people.

The provider could not demonstrate that they promoted people’s privacy and dignity. People liked the staff. Peoples religious wishes and beliefs were recorded. Relationships with family were encouraged and maintained.

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 had choice over what they ate, and their nutritional needs were met.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was requires improvement. (report published 29 August 2018)

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to the premises and equipment and 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 15 June 2018

During a routine inspection

We undertook our comprehensive inspection of Everley on 15 and 18 June 2018. The initial visit date was unannounced with the second date announced. Our last inspection of Everley was on 01 December 2015. The service was rated good after this inspection.

Everley is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Everley accommodates a maximum of 16 older people that may have dementia or physical disabilities. People live in a building that was converted into a care home.. There was 16 people living at the home on the first day of inspection, and 15 on the second.

The provider is required to, and has a registered manager for the home. They were present throughout our inspection. 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.

People felt there was enough staff to keep them safe, and respond to their requests for assistance in a timely manner. Staff were of the view additional staff may help improve people’s safety and the provider was reviewing staffing levels on a monthly basis in response.

Improvement was needed to ensure that systems for infection control were effective. People received their medicines in a safe way. People felt safe and there were systems in place to identify and respond to risks. Staff were aware of safeguarding systems, although improvement in recording equipment people may use for lifting could be improved.

People’s rights were promoted. Staff sought people’s consent. Risks to people’s health were assessed and identified. Staff were supported and had received training although some training needed update. The provider had sourced a new training provider to update staff on key areas of skill and knowledge relevant to their job. People were supported to maintain a healthy diet, good fluid intake and had a choice of meals. People were supported to access the health care they needed.

The environment was small and homely although may not always be suitable for people with limited mobility if accommodated on the first floor. There was scope for improvement in respect of the environment regarding its decoration, and safety in respect of, for example infection control.

People were supported by staff who were caring and treated them with dignity and respect. People were valued by staff. People's independence was promoted. People were supported to express and make choices regarding their daily living. People were supported to maintain contact with significant others.

People and their representatives were involved in their care planning. Staff understood people's needs, likes, dislikes and personal preferences. People had the opportunity to engage in activities if they wished. People could make a complaint and thought they would be listened too. The provider was working with health professionals to develop ways of responding to people’s wishes and needs at times when they may be unable to share these.

Systems for quality monitoring were in place, but development of these needed to continue to address some aspects of quality within the service. The management team were well known to people, relatives and staff, who considered them approachable. The provider understood their legal responsibilities and were open and honest about the challenges faced in respect of improving the service so people were safe and received good quality care. We found the provider was learning from incidents and events following input from other agencies.

Inspection carried out on 1 December 2015

During a routine inspection

This was an announced inspection which took place on 1 December 2015. Everley Residential Home provides accommodation with personal care for 16 people who may have needs due to old age, physical disability, or dementia. On the day of our inspection 12 people lived at the home.

The provider Thames Williams Care is a new legal entity previously under The Jethwa Partnership, and this is their first inspection.

At our last inspection in October 2014 the previous provider was not meeting all of the regulations that we assessed. They had not ensured that an effective system was in place to prevent people being unnecessarily deprived of their liberty. At this inspection we found that the previous provider had made improvements and that people received care in line with their best interests and processes were in place to ensure they were not restricted unlawfully.

There was a registered manager at the home. 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.

People had no concerns about their safety. Risks to their safety had been identified and staff had training in how to recognise and report abuse.

Staff were recruited in a safe way and had relevant training and support to develop their skills in meeting people’s needs. People were cared for by staff who knew them well and responded to their needs. We saw that there were some occasions where staff were not visible in communal areas. The staffing levels had not been reviewed regularly to ensure there were enough staff to meet people’s needs.

People had their medicines when they needed them and staff had been trained to manage medicines safely. Staff had written guidance to support people with their medicines so that they were administered safely.

Staff were aware of people’s individual needs and how to respond to risks to their health such as falling or developing pressure sores. People and their relatives were complimentary about the quality of the care they received.

Staff were aware of the importance of seeking people’s consent before care was carried out. We saw staff respected people’s choices. We saw staff understood the Deprivation of Liberty Safeguards (DoLS). They had followed these procedures when people’s liberty had been restricted for their own safety.

People were happy with the meals offered and were appropriately supported to have their meals. Drinks were offered throughout the day to prevent the risk of dehydration. People’s health was supported by access to appropriate health professionals.

We saw that staff were attentive and caring towards people. People described the staff as being friendly and kind. Relatives told us the staff were polite, patient and respectful towards people.

People had access to spontaneous activities. However the availability of staff to enable regular activity to take place needed reviewing.

People told us that they were happy living at the home. They knew how to raise any concerns if they needed to and we saw arrangements were in place to listen and act upon any concerns.

People described the management of the home as very friendly and approachable. Although the ownership of the home had recently changed the registered manager had not changed which maintained some consistency and ensured the service ran smoothly. The provider had a vision for the future and an action plan to make improvements within the home.

Quality monitoring systems were in place and the registered manager had made improvements so that the home was run in the best interests of the people who lived there.