CQC report explained · a residential care home
What the CQC found at Eversley Rest Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found safety and management systems were not robust enough, although staffing and safeguarding were in place.
This was an unannounced focused inspection on 3 October 2023. Inspectors looked only at Safe and Well-led because the inspection was prompted by concerns about care and service management. They spoke with people, relatives and staff, and checked care records, medicines, recruitment files, building safety records, audits and incident records.
The home was not always safe. Inspectors found gaps in risk assessments and care plans, medicines were not always managed safely, some building safety checks were late or incomplete, and there were infection control concerns. They found no evidence that anyone had been harmed, but said people were at increased risk.
The home was also not always well-led. The systems used to check quality and safety did not identify several of these problems. The provider had started to address some issues after the visit, and CQC requested an action plan and will monitor progress.
Staffing
Inspectors found there were enough staff to support people. Relatives and staff also said staffing levels were adequate.
“There were enough staff although some improvements could be made to the recruitment process.” from the report
Safeguarding
People said they felt safe, and staff understood how to recognise and report possible abuse.
“Staff understood how to keep people safe from the risk of abuse and knew where to access policies as well as how to raise a concern.” from the report
Visitors
People were able to receive visitors without restrictions.
“People were able to receive visitors without restrictions in line with best practice guidance.” from the report
Open culture
Inspectors found that people, relatives and staff could be involved in care planning and raise concerns or suggestions.
“There was a positive and open culture at the service.” from the report
Risk assessments and building safety
seriousSome windows did not have compliant restrictors when inspectors visited, and the annual gas safety check had not been completed on time. Care plans and risk assessments also lacked important information about people’s risks.
“The provider did not always assess risks to ensure people were safe.” from the report
Medicines
seriousSome medicines prescribed for use when needed did not have instructions for staff. Stock discrepancies meant the manager could not be sure medicines were always given as prescribed.
“People's medicines were not always safely managed.” from the report
Learning from incidents
needs fixingIt was not clear that incidents were being analysed for patterns and lessons. This limited the home’s ability to prevent problems happening again.
“Where incidents had taken place, it was not clear if this information had been analysed to identify patterns and trends so measures could be put in place to reduce the incidents reoccurring to keep people safe.” from the report
Cleanliness and equipment
needs fixingSome furniture was damaged, some communal equipment was rusty, and some areas and equipment needed more thorough cleaning.
“Some furniture in the home was damaged and some equipment in communal areas was rusty which would have made it difficult to clean these effectively.” from the report
Management checks
seriousThe provider’s checks did not identify several safety problems, including risks involving windows, gas checks, care plans, medicines and legionella management.
“Governance systems were not robust enough to demonstrate safety was effectively managed.” from the report
- 01What has been done to make all window restrictors compliant, and how are building safety checks now monitored?
- 02How are medicines prescribed for use when needed now supported by clear instructions and accurate stock checks?
- 03Have care plans and risk assessments been updated with enough detail about conditions such as diabetes and other individual risks?
- 04How are incidents, accidents and near misses now reviewed for patterns and lessons?
- 05What changes have been made to cleaning, damaged furniture, rusty equipment and the management of legionella risks?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection published on 6 May 2021. This explanation was written from the published report of 5 December 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, May 2021
Rated Good; inspectors found safe care and improved management, with a few minor issues addressed during the inspection.
The home cared for 23 older people and could support up to 28. Two inspectors made an unannounced visit on 24 March 2021. They spoke with people and staff, observed care, and checked care, medicines, recruitment and management records.
The home was rated Good overall. Safe was rated Good, including staffing, medicines, risk management and infection control. Inspectors found people felt safe and that staff understood their needs. They were assured that the home was following national COVID-19 guidance.
The inspection was focused on Safe and Well-led because concerns had been raised about staffing. Well-led improved from Requires Improvement to Good. The other three areas were not inspected at this visit, so their previous ratings were used in the overall rating.
Staffing matched people’s needs
The home was using a staffing tool consistently, and inspectors found that staffing hours were often above what the tool suggested. People’s needs were met with the staff available.
“There is always enough staff around to help us.” from the report
Medicines were managed safely
Medicines were given on time by trained staff. Audits were more effective at finding errors, and action was taken when problems occurred.
“Staff are always on time with my medicine and keep track of what I need.” from the report
Management had improved
Governance systems were stronger than at the previous inspection. The home used audits and reviews to identify actions and check that they were completed.
“At this inspection we found significant improvements had been made.” from the report
Infection controls were in place
Inspectors were assured that the home was using PPE, testing, cleaning and social distancing measures appropriately. A visitor pod helped people maintain contact with others.
“We were assured that the provider was using personal protective equipment (PPE) effectively and safely.” from the report
Bath equipment needed replacement
minorA chair used to help people get in and out of the bath needed replacing. The home had ordered a replacement and said it would be replaced shortly.
“a chair to support people get in an out of the bath needed replacement.” from the report
One recruitment record was incomplete
minorOne new staff member did not have a full employment history recorded. The home acted immediately and obtained the missing information.
“We found one new recruit who had not documented their full employment history.” from the report
- 01What are the current staffing levels, and how do you check they match each resident’s needs?
- 02How has the change to the registered manager been managed, and who is currently responsible for day-to-day care?
- 03What are the current ratings for Effective, Caring and Responsive, which were not inspected during this visit?
- 04Has the replacement bath chair been fitted, and are all other equipment checks up to date?
- 05How do you check that staff recruitment records, including full employment histories, are complete?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings carried over into the overall rating. This explanation was written from the published report of 6 May 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 Eversley Rest Home
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2021Goodstayed GoodSafe: GoodWell-led: Good
- October 2018Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- August 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015
Registered with the Care Quality Commission on 26 May 2015.
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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