CQC report explained · a residential care home
What the CQC found at Eversfield House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found unsafe risks in the building, medicines and records, although staff knew people well and provided kind support.
This was an unannounced, focused inspection on 26 April 2023. One inspector spoke with six people and four staff, reviewed five care records and other records, and observed the environment and care.
The home was not always safe. Some windows could open too far, and people could reach a flat roof from a fire escape without barriers. Medicines records were inaccurate, medicines were not always checked as taken, and medicines were handled in a way that increased contamination risk.
The home did not have effective checks on care quality. Audits had not been completed for several months, care records lacked important risk information, and there were no clear improvement plans. These issues led to breaches of Regulation 12 and Regulation 17.
Staff were observed supporting people safely and knew their needs. People said they felt comfortable raising concerns, and the home worked with health and social care professionals. The overall rating fell from Good at the previous inspection to Requires Improvement.
Staff knew people well
Inspectors saw staff supporting people safely and understood their individual risks and needs.
“Despite the concerns identified above, we observed staff supporting people safely and they were knowledgeable about the individual risks to people living at the service.” from the report
People felt comfortable speaking up
People said they felt able to approach the manager and share their views. The report also says people were involved in decisions and supported in the least restrictive way.
“People and staff told us they felt comfortable approaching the manager and having open conversations with them.” from the report
Enough staff were on duty
Inspectors found there were enough staff to meet people's needs, and recruitment checks were in place.
“There were sufficient numbers of staff on duty to meet people's needs.” from the report
Good partnership working
The home worked with the GP and the local authority care home support team when people had health or welfare concerns.
“The service worked closely with other health and social care professionals in order to meet the needs of the people living there.” from the report
Risks in the building
seriousSome windows could be opened wider than recommended. The fire escape led onto a flat roof, with no barriers to stop people reaching it and falling.
“There were no barriers in place to prevent people from going onto the flat roof or protect them from falling from height.” from the report
Medicines were not managed safely
seriousStaff signed records before medicines had been taken, recorded some medicines as refused incorrectly, and handled medicines in their bare hands. Inspectors said this placed people at risk of harm.
“Staff signed MAR to indicate people had taken their medicines before giving these to them.” from the report
Care records lacked important information
seriousRecords did not set out people's risks and support needs in enough detail. This could mean staff did not have the information needed to provide safe care.
“Care records did not contain detailed information about people's support needs, risks to their safety or how they were to be supported.” from the report
Weak quality monitoring
needs fixingAudits had not been completed in the months before the inspection, and there was no clear improvement plan. Staff training records were also not accurate enough for proper oversight.
“There were no systems in place to identify the concerns we found during inspection, and there was no clear programme for making improvements.” from the report
- 01What has been done to repair and restrict the windows, and to prevent people reaching the flat roof from the fire escape?
- 02How are medicines now handled, recorded and checked to make sure they are taken at the correct time?
- 03Have all care records been updated with each person's risks, support needs and medicine arrangements?
- 04Which quality audits have now been completed, and how often will they be reviewed?
- 05How are staff training records being checked, including when refresher training is due?
This was a focused inspection of Safe and Well-led only; the other key question ratings carried over from the previous inspection and were not inspected on this visit. This explanation was written from the published report of 26 May 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2021
Inspected but not rated; inspectors found good leadership and improved infection control, with some individual risk assessments not formally recorded.
This was a focused inspection after concerns about infection prevention and control and how the service was overseen. Inspectors spoke with people, care workers and the registered manager, observed the home, checked infection control processes and reviewed records and information from the local health service.
Inspectors found that infection control had improved. They were assured about visitors, social distancing, protective equipment, testing, cleaning and visits. Staff supported people to keep in touch with relatives by phone, video calls and visits, including through a garden visiting pod.
The home was well-led and received a Good rating for this area. The provider had regular checks on care records, medicines records, risk assessments, staff records and training. However, some risk assessments for individual staff and people had been considered but were not formally recorded.
The overall service and Safe rating were inspected but not rated. The previous overall rating was Good, published in February 2018. This inspection did not re-rate Safe and did not assess the other three areas.
Improved infection control
The home had improved after a local health service audit. Inspectors were assured that the main infection control arrangements were in place.
“We found they had improved since this audit and the CCG confirmed all the concerns they raised had been resolved after our inspection.” from the report
Safe use of protective equipment
Staff had training, enough protective equipment and a suitable area for putting it on and taking it off. Inspectors saw staff following the guidance.
“Our observations during the inspection confirmed staff were adhering to PPE and social distancing guidance.” from the report
Contact with relatives
The home helped people stay in contact with loved ones through calls and visits. A garden pod allowed visits without relatives entering the home.
“Staff supported people to keep in regular contact with loved ones through regular phone and video calls and visits in line with guidance.” from the report
Good leadership
Inspectors found experienced leadership and said people and staff spoke positively about how the home was managed.
“The registered manager was experienced and understood their role and responsibilities, as did staff.” from the report
Quality checks
The provider had a broad programme of checks covering care, medicines, risk assessments, staffing and training. Improvements were addressed promptly.
“There was a comprehensive programme in place to review the quality and safety of the service.” from the report
Risk assessments were not formally recorded
needs fixingThe manager had considered risks for some individual staff and people and had taken precautions, but the assessments had not been written down formally at the time of inspection.
“However, they had not recorded these assessments formally.” from the report
- 01Have all individual risk assessments now been formally recorded, and when were they last reviewed?
- 02What changes were made after the local health service infection control audit?
- 03How are visitors screened, tested and supported to visit people safely now?
- 04How will relatives and people using the service be involved while regular meetings remain affected by circumstances such as the pandemic?
- 05How often are care records, medicines records and risk assessments checked, and what happens when a problem is found?
This was a focused inspection of Safe infection control arrangements and Well-led; Safe was not re-rated and Effective, Caring and Responsive were not assessed. This explanation was written from the published report of 16 June 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Eversfield House
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Good
- March 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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