Eversleigh Care Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Our rating for this key question has changed from requires improvement to good. However, improvements were needed to the system used for oversight of medicines and incidents to ensure timely, appropriate action was taken in response to incidents and events. Improvements were also needed to ensure staff training was up to date to ensure the care provided by staff reflected current best practice. People felt safe. Staff understood their responsibilities to raise any concerns about people’s care. Staff and leaders understood people’s risks and managed them effectively. People received their medicines as prescribed and there were systems in place to monitor the safety and cleanliness of the home environment.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were able to tell us about action that had been taken following incidents and events. This included action taken to reduce the risk of incidents happening again.

Staff could describe how incidents were recorded and reported. They were aware of actions taken following incidents and told us care plans and risk assessments were reviewed to reduce risk. One staff member described how additional welfare checks had been implemented to maintain a person’s safety.

Records reflected evidence of learning from incidents and events. However, action plans used for management oversight were not always clear about how learning was shared and monitored. For example, 1 action plan stated communal areas should always be supervised by staff, but staff acknowledged this would not always be possible. The area manager told us this would be reviewed to ensure any changes or learning were attainable with current staffing levels.

We received mixed views about people's transitions into the home. Some of this feedback related to people leaving hospital, which could not always be influenced by the management team. Others expressed more positive views. One person said, “When I first came in, I needed a lot of support and had to call staff in the night…they came straight away and didn’t mind me calling them.” The majority of feedback about people’s initial move into the home was positive.

Staff were aware of people who were staying at the home for a period of respite, or on a short term basis. They told us a shorter care plan was used for people whose stay at the home was planned to be short term. The management team told us they had made changes to their admissions procedures and this improved the quality of care provided to people when they first moved into the home.

Partner agencies shared some concerns about when people moved between different areas of the home. For example, when a person was moved to a different unit as they needed a higher level of care, in the visiting professional’s view the person did not receive the level of care they required, and they in fact felt they received less support from staff. Partner agencies did not share any concerns in relation to people’s transitions in and out of the home or in relation to referrals.

Systems used for the management of care were established and used to provide oversight of people’s experience of care. However, while care plans for people on short term stays contained essential information, they required more detail to ensure people received personalised care which was tailored to their individual needs.

People told us they felt safe and trusted staff to support them safely. One person said, “The staff are good, I don’t worry about them. I feel very safe here. The staff are all nice."

Staff were aware of how to keep people safe and knew how to identify signs of potential abuse. The management team understood their safeguarding responsibilities and had reported any concerns for people’s safety to the local authority as required.

We did not observe any safeguarding concerns during our site visit. The care and support we observed was safe.

There were systems in place for the management and reporting of safeguarding events or incidents, which staff followed when needed. There was a whistleblowing policy in place and processes for the application and monitoring of Deprivation of Liberty Safeguards (DoLS), which ensured any restrictions were lawful.

People told us staff understood how their risks could impact them and were mindful of their risks when providing support. Examples shared with us included how staff managed people’s risks when they walked using mobility aids.

Staff were aware of people’s risks and told us they followed guidance in care plans to protect people from avoidable harm. They shared examples with us of actions they had taken to reduce risks posed by dehydration and mobility needs. Staff told us there was clinical oversight, completed by nursing staff, with regard to people’s needs and this was further supported by the management team.

We observed staff supporting people safely. This included when supporting them with their mobility, eating and drinking and repositioning to reduce the risk of skin damage.

There were systems in place to assess people’s individual risks and guidance was accessible to staff to enable them to support people safely. Care plans were reviewed regularly, as well as when people’s needs changed, which enabled staff to provide care that met people’s current needs. Monitoring systems were in place which staff completed to confirm people had received their planned care, such as repositioning. The management team had oversight of this in real time and also reviewed information daily to support the safe management of risk.

People told us they felt the home environment was clean, safe and well maintained. One person said “I feel safe here, they really look after you."

Staff told us they had no concerns about the quality or safety of the equipment they used. They told us anything they reported was actioned straight away and they did not have to wait for repairs. The operations manager told us regular checks were carried out to ensure the safety of equipment and any concerns were acted upon without delay.

We observed the home was clean and well maintained. Cleaning was on-going throughout the day and equipment used was in good order.

There were established systems in place which included daily, weekly and monthly checks to ensure equipment and the environment was safe. We reviewed records which showed where concerns had been noted appropriate action had been taken to rectify any issues.

People told us there were enough staff available to meet their care needs. However, some people reported that although staff were available to provide care and support, they did not always have time to talk to them. Some people reporting delays when using the call bell system, although they said staff did respond, but not always in a timely way.

The operations manager acknowledged some staff training was not up to date. They advised work was on-going to ensure the required staff training was completed. They told us this was being addressed and training sessions had begun to take place to bring staff skills and knowledge up to date. Staff we spoke with described staffing levels as safe. They told us they had completed an induction when they began working at the home and had received training to improve their skills and knowledge. They told us they felt supported in their roles and could approach the management team with any concerns. The management team told us they had reduced the use of agency staff and monitored the staffing levels across the different areas of the home. They confirmed staffing levels were calculated based on assessments of people’s needs.

We observed there were enough staff to respond to people when needed and provide planned care in line with people’s needs. Where we observed staff using moving and handling techniques to support people with their mobility, there were enough staff to ensure this was done safely.

Training records reflected gaps in staff training, including first aid and basic life support. Most staff had previously completed this training but required refresher training to ensure their knowledge was up to date with current practice. There were systems in place to assess people’s needs in terms of staffing and staffing allocations were managed to ensure people’s needs were met. Recruitment processes were in place and appropriate checks had been carried out on newly recruited staff to ensure they were safe to work with people.

People told us their rooms were cleaned regularly and the home was clean and tidy. A relative told us, “It’s spotless in here, they are always cleaning. They hoover up at least 3 times daily."

Staff told us they had received training in how to sanitise equipment, handwashing, the use of Personal Protective Equipment (PPE) and minimising the risk of cross infection. Leaders told us infection control training was in place for staff and guidance was provided in the event of any outbreaks of infection.

We saw PPE stations were situated throughout the home and were well used by staff. We observed staff changed gloves and aprons and washed their hands in between supporting different people, to reduce the risk of cross infection.

There were systems in place to ensure Infection Prevention and Control (IPC) was monitored throughout the home. Cleaning schedules ensured daily cleaning took place and IPC audits were undertaken to address any areas of concern.

People told us they received their medicines as and when they needed them. One person said, “They [staff] bring me my medicines every morning."

Staff were able to explain their responsibilities in relation to people’s medicines. They told us they used handheld electronic devices to record any medicines administered and were prompted to administer people’s medicines in accordance with the prescribers instructions. Senior staff told us they followed the provider’s policy and guidance when managing medicines and also had access to national guidance if required.

Records we reviewed confirmed people received their medicines as prescribed. However, covert medicine protocols required clarity to ensure medicines were being added to food/drink approved by a pharmacist. Systems in place to monitor stock levels, particularly for ‘as required ‘medicines required review as these were not always effective. Audits were in place to monitor the management and administration of medicines, however these had not been completed consistently and did not always identify actions taken to address any identified concerns.