CQC report explained · a nursing home
What the CQC found at Eversleigh Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found enough staff and improvements in safety, but gaps in care and medicines records were not acted on.
This was an unannounced focused inspection on 20 June 2023. Inspectors checked whether the home had acted on an earlier improvement plan, mainly for Safe and Well-led. They spoke with people, visitors and staff, observed care, and reviewed records and recruitment files.
The home had enough staff, safe recruitment, good infection control and systems for responding to incidents. People said they felt safe, and staff understood how to recognise and report abuse. However, care records did not always show that repositioning and fluid monitoring had happened. Medicines records were also incomplete, so the home could not always be sure medicines had been given.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The home had improved and was no longer in breach of Regulations 12 and 18, but it remained in breach of Regulation 17 because its checks did not lead to action when problems were found.
Enough staff
Inspectors found enough staff to support people promptly. Recruitment checks were also carried out safely.
“Staff were recruited safely. The provider had checks in place to ensure staff were suitable to work with people” from the report
People felt safe
People and relatives said the home felt safe. Staff knew how to identify possible abuse and report concerns.
“People and relatives told us the home felt safe.” from the report
Infection control
Inspectors were assured that the home used infection control measures, including safe admission processes, effective protective equipment and suitable hygiene practices.
“We were assured that the provider was using PPE effectively and safely.” from the report
Learning from incidents
The home reviewed accidents and incidents, took follow-up action and shared lessons with staff.
“Lessons learned were identified and shared with the staff team for example, using the handover processes in place and regular meetings and supervision.” from the report
Person-centred relationships
Staff knew people well and had taken time to understand their preferences. People and relatives also reported a positive atmosphere.
“People received person centred care. Staff knew people well and had spent time getting to know and understand people's preferences for their care.” from the report
Incomplete care records
seriousRecords did not always show that planned care had been delivered. This included repositioning people at risk of sore skin and recording fluid intake.
“The provider could not be sure people had received their care as required.” from the report
Medicines records
seriousSome medicines administration records had missing signatures and some stock counts did not account for medicines. This meant the home could not be confident that prescribed medicines had been given.
“This meant there were no record of these medicines being administered and the provider could not be confident people had had their prescribed medicines.” from the report
Checks did not lead to action
seriousThe home's electronic alerts and quality checks identified missing care records, but there was not enough evidence that staff acted on them. This left people at risk of harm.
“The systems in place to ensure accurate records of the care people received had failed to ensure action was taken when gaps were identified.” from the report
- 01How do you now check that repositioning and fluid monitoring have been completed and recorded?
- 02What checks are now made to ensure every medicines administration record is signed and stock counts are accurate?
- 03What happens when the electronic system identifies a missing care record or medicines entry?
- 04What evidence can you show that the changes made after the inspection have been working?
- 05How will you keep families informed about progress following the Warning Notice?
This was an unannounced focused inspection of Safe and Well-led; the ratings for Effective, Caring and Responsive were carried over from the last inspection. This explanation was written from the published report of 30 September 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, April 2023
Rated Requires Improvement; inspectors found unsafe gaps in staffing, risk management, medicines records and quality checks.
The inspection was unannounced and took place on 7 February 2023. Inspectors spoke with people, a visitor and staff, and reviewed care records, medicines records, recruitment files and quality checks.
The home did not always manage risks safely. Some people waited too long for repositioning or help with food and fluids. Medicines records had gaps, and there were not always enough staff to meet people's needs promptly.
Management checks did not reliably identify these problems. The home did not have a registered manager at the time. Inspectors rated Safe and Well-led as Requires Improvement. The overall rating changed from Good at the previous inspection because this was a focused inspection of those two areas.
Infection control
Inspectors were assured that the home was managing infection prevention, visitors, protective equipment and possible outbreaks appropriately.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Safeguarding awareness
Staff knew how to recognise possible abuse and understood how to report safety concerns.
“Staff knew how to identify concerns for people's safety and could recognise signs of possible abuse.” from the report
Mental capacity safeguards
Inspectors found that the home was working within the Mental Capacity Act principles and that required legal authorisations were in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Working with professionals
The home worked with visiting healthcare professionals and other partner agencies when planning and providing care.
“The management and staff team worked alongside visiting healthcare professionals and other partner agencies” from the report
Risks to skin and hydration
seriousSome people did not receive repositioning as often as their care plans required. Fluid records were incomplete, so staff could not always tell whether people had drunk enough.
“Records reflected there had been periods of up to 6 hours in between support given to reposition people.” from the report
Staffing delays
seriousThere were not always enough staff to help people with eating, drinking or repositioning. Inspectors saw people waiting for responses and food left where staff support was required.
“There were not sufficient numbers of suitably qualified, competent, skilled and experienced staff deployed to meet people's care and support needs.” from the report
Medicines records
seriousMedicines administration records had gaps, so inspectors could not be sure that people had received their medicines. Checks intended to identify these gaps were not consistently evidenced.
“There were gaps on Medicines Administration Records (MAR) which meant we could not be sure people had received their medicines.” from the report
Weak management checks
seriousAudits and daily checks did not identify the problems inspectors found. Staffing assessments did not always reflect people's individual needs.
“Governance and oversight systems used by the home's management team were not effective at identifying areas of concern or making improvements.” from the report
No registered manager
needs fixingThere was no registered manager in post when inspectors visited. The home was being overseen by the nominated individual.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01What has changed in staffing levels, and how do you now match staffing to each person's individual needs?
- 02How do you make sure people receive repositioning on time and get the help they need with eating and drinking?
- 03How are medicines administration records checked each day, and what happens when a record is incomplete?
- 04What improvements have you made to audits and daily checks following the Warning Notice?
- 05Who is currently responsible for managing the home, and how are relatives able to raise concerns?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 6 April 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.
Every inspection of Eversleigh Care Centre
8 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- September 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2023Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2022Goodup from Requires improvementSafe: GoodWell-led: Good
- December 2021Requires improvementdown from GoodSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2018Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Good
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 28 February 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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