CQC report explained · a nursing home
What the CQC found at Eversleigh Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2019
Rated Good overall, but Safe required improvement because some safety checks and records were not reliable.
Inspectors made an unannounced visit on 15 May 2019. They spoke with people living at the home, relatives and staff. They observed care and reviewed care, medicines, staffing and quality records.
People told inspectors they felt safe. There were enough staff, medicines were generally given as prescribed, and care was kind and personalised. Staff supported people's nutrition, healthcare, choices, dignity and activities.
The Safe rating was Requires Improvement. Inspectors found problems with checks on windows, evacuation equipment, bed rails and thickener storage. Some records about diabetes and feeding tubes were also incomplete. The provider took immediate action to address the issues.
The home was rated Good overall, with Good ratings for Effective, Caring, Responsive and Well-led. This was the same overall rating as the previous inspection in 2016, although Safe had fallen to Requires Improvement.
Enough staff
Inspectors found enough clinical and care staff with the skills and experience needed to meet people's needs.
“There were enough clinical and care staff with the appropriate skills, knowledge and experience to meet people's needs and provide effective care.” from the report
Kind and respectful care
People and relatives spoke positively about staff's kindness. Inspectors saw warm relationships and respectful support.
“Staff interacted with people in a kind and respectful way and had established warm relationships with them.” from the report
Personalised activities
People were offered activities linked to their interests, and the home used forums and themed days to shape the programme.
“People were offered opportunities to engage in activities and events they were interested in.” from the report
Good end of life support
Staff had training and experience in end of life care. People were supported to plan care around their preferences.
“Staff were skilled and experienced in end of life care and understood people's needs.” from the report
Positive improvement work
Managers had introduced projects to improve contact with people in their rooms, communication and staff efforts to make a difference.
“The registered manager had introduced several initiatives at the home to improve outcomes for people and to raise quality standards.” from the report
Safety checks missed hazards
seriousChecks did not identify three windows without suitable restrictors, missing evacuation equipment and a bed rail without protective bumpers or a risk assessment. The provider arranged immediate action.
“However, we found some risks had not been identified.” from the report
Incomplete risk records
needs fixingRecords did not always show how risks linked to diabetes and feeding through a tube were being managed. A new recording system was introduced immediately.
“There were insufficient records to support management of risks around diabetes and when people were fed through a tube directly into their stomach (PEG).” from the report
Unsafe thickener storage
seriousThickening powder was accessible in a person's bedroom. It was removed immediately and staff were reminded about the risks.
“Thickener was found in one person's bedroom which meant it was accessible to people as they walked around the home.” from the report
Some medicines paperwork
needs fixingFour missing instructions for medicines given when needed were replaced. Handwritten changes to medicines records were not always checked and signed by a second staff member.
“However, we found handwritten amendments to the MARs had not always been signed by a second member of staff to ensure their accuracy.” from the report
Snack records unclear
needs fixingSome people were at risk of losing weight, but records did not make clear that they were consistently offered high-calorie snacks. The manager had already identified this.
“Some people were at risk of losing weight, but it was not clear they were consistently offered snacks fortified with extra calories.” from the report
- 01What action was taken to fit the missing window restrictors, provide the evacuation equipment and add the bed rail bumpers?
- 02How are safety checks now recorded so that hazards are identified promptly?
- 03How do you record and review risks for people with diabetes or PEG feeding?
- 04How are thickening powders stored and controlled so they cannot be accessed by residents?
- 05How do you make sure people at risk of weight loss are consistently offered fortified snacks?
This was a planned inspection covering all five CQC questions, including the premises and care provided, and it reviewed the overall rating. This explanation was written from the published report of 19 June 2019 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, December 2016
Rated Good; inspectors found safe, kind and responsive care, with some communication concerns during a management change.
This was an unannounced inspection. Inspectors spoke with people living at the home, relatives, staff and managers. They observed care and mealtimes, and checked care plans, medicines, staff records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, suitable training, safe medicines practice and care records that were kept up to date.
People were treated with kindness and respect. They were supported with food, activities, healthcare, personal choices and family relationships. Complaints were investigated, and the provider used checks and feedback to make improvements.
There had been a change in management. The registered manager was away and planning to leave, while a new manager was taking over. Some staff said communication and formal team meetings had been weaker during this period, but meetings had restarted by the inspection.
People felt safe
People told inspectors they felt safe, and staff understood how to recognise and report abuse. Risk assessments gave staff clear instructions for supporting people safely.
“All the people we spoke with told us they felt safe at the home.” from the report
Kind and respectful care
Staff knew people well and supported their privacy, dignity, independence and everyday choices. Inspectors saw respectful interactions and relatives described staff as kind.
“We observed staff interacting with people at the home in a respectful and caring way using people's preferred names.” from the report
Food and healthcare
People could choose meals and alternatives, and staff supported different dietary needs. People were referred to healthcare professionals when needed, and professional advice was followed.
“People were offered food and drinks that met their dietary needs.” from the report
Activities and relationships
People were supported with hobbies, one-to-one activities and trips out. They could choose visitors and use private or communal areas to maintain relationships.
“People enjoyed the activities and events on offer at the home.” from the report
Checks led to improvements
The provider used audits, surveys, meetings and complaint reviews to identify areas for improvement. Action plans were monitored by the provider.
“This demonstrated the provider took action to continuously improve the quality of the service provided at the home.” from the report
Communication during management change
needs fixingSome staff wanted more communication while the registered manager was away. Staff morale had been affected by uncertainty, although the management change had been communicated and the new manager had started to reintroduce meetings.
“some staff commented they would have liked more communication from the management team in the registered manager's absence.” from the report
Limited conversation during some care
minorInspectors saw that staff did not always use opportunities to talk with people, including during help with eating. This was a shortfall in the quality of interaction, although the overall caring rating was Good.
“However, some of the time staff did not take the opportunity to speak with people when they could.” from the report
Formal staff meetings had lapsed
needs fixingStaff said formally arranged team meetings had not taken place regularly while the previous manager was absent. The last full team meeting had been in April 2016, but meetings had restarted by the inspection.
“The last full team meeting was held in April 2016.” from the report
- 01How have communication and formal staff meetings been maintained since the new manager took over?
- 02How do you make sure people receive enough support to eat at every mealtime?
- 03How are staff given time to talk with people during personal care and meals?
- 04How are each person's food preferences, dietary needs and alternatives recorded and shared with kitchen staff?
- 05How will you involve our relative and family in care plan reviews and decisions about their care?
This was an unannounced comprehensive inspection looking at the overall quality of the home and all five CQC questions. This explanation was written from the published report of 21 December 2016 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 Nursing Home
3 rated inspections over 3 years: the service has held its Good rating throughout.
- June 2019Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 14 December 2010.
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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