Eversleigh Care Centre

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Our rating for this key question has changed from requires improvement to good. People and staff spoke positively about the recent changes to the management team. Improvements to governance processes had been improved since the last inspection and this had improved the quality of daily checks carried out to ensure people’s care needs were being met. However, staff and partner agencies expressed concerns about the instability of management within the home and felt this impacted people’s care. Further improvements to monitoring systems and processes used to monitor incidents, medicines and people’s care were required, to ensure effective action could be taken where concerns were identified.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed views from staff about the culture at the home. Some staff told us that numerous changes in the management of the home had impacted staff morale. Other staff told us they had been unaffected by changes in the management team and felt consistency had been provided, in recent months, by the operations manager.

New processes had been put in place to improve communication and culture at the home. These needed time to embed and become effective. The operations manager was working at the home on a daily basis to support the staff team and provide consistency. A new home manager had been recently appointed and was undertaking their induction at the time of the assessment.

Staff feedback about leaders was positive despite the recent management changes. One staff member said, “It’s a friendly place to work. The operations manager is really nice.” Other staff commented on the actions taken by the management team to improve people’s experience of care.

The provider had policies in place to offer guidance to leaders about how staff members' diverse needs should be considered. This included from the point of recruitment, as well as during employment and training.

Staff told us they were confident to raise concerns or complaints with senior staff or the management team. One staff member said, “I have no issue, I would easily approach the managers with any concerns.” The management team told us they were visible around the home on a daily basis. They said senior staff also discussed any concerns staff may have in one to one meetings.

The management team operated an open door policy, to ensure staff could speak with them if and when they needed to. The provider had a whistleblowing policy in place, which was easily accessible by staff, to promote speaking up and offer protection to staff who raised concerns.

Staff told us their cultural and diverse needs were considered by the provider and the leaders within the organisation. The management team shared examples with us of how they had provided additional support to staff with learning needs and gave consideration to people’s diverse needs when providing supervision and training.

Training records reflected staff had undertaken training in equality, diversity and human rights, to promote inclusion within the staff team.

Staff told us they were required to report any concerns about the quality of care to the management team. They told us they were aware that senior staff and the management team carried out regular checks on all aspects of people’s care. Senior staff told us they used a ‘resident of day’ system which enabled them to regularly review people’s planned care needs and update their care plans and risk assessments. They also carried out checks in relation to the medicines management system, as well as night-time checks. The management team told us they had improved the range of checks and audits in place to monitor, review and improve the quality of care people received.

There were processes in place to monitor the quality of care people received. These included daily, weekly and monthly checks and audits covering areas such as wound management, dietary intake, medicines management and incident management. Improvements had been made since the last inspection. However, we found audits used for the management of medicines and the management of incidents were not always effective in identifying concerns or taking appropriate action to drive improvement.

People and relatives told us they were aware staff worked in partnership with other agencies to meet people’s needs.

Staff told us they worked alongside local professionals to support people’s health and wellbeing. This included community health care teams, social workers and pharmacists. One staff member told us, “We work closely with the GP, we follow the instructions they give to help people manage their health.” The operations manager told us that due to inconsistency of management at the home they had not always worked well with local agencies. They told us they, and the newly appointed manager were taking action to address this and were working with the local authority and Integrated Care Board to support on-going improvements at the home.

Partner agencies shared mixed views about the service as a whole. While feedback included positive views of unit managers and staff, feedback from partners consistently reflected concerns about inconsistency of management at the home and the potential impact on people’s experience of care.

The management team also worked with external agencies, who carried out audits to assess the quality of care provided. The operations manager acknowledged that these working relationships needed to be improved and plans were in place for the newly appointment manager to attend local registered manager forums to support and develop their knowledge. Processes were in place to ensure the staff worked in partnership with people and their relatives. This included regular conversations with people about their care. Resident’s and relative’s meetings had also recently been re-established and the management team were acting on feedback given, in particular concerns raised about the quality of food and mealtimes. There were processes in place so that learning could be shared with other services operated by the provider. This aimed to ensure that people could be protected from avoidable harm.

Staff told us they could share ideas with the management team and felt they were listened to. They also shared examples of where learning had been shared following incidents. The management team told us they planned to make better use of their incident review process and audits to gather learning that could be shared with the staff team. They told us they were improving systems to enable them to identify areas of concern more quickly so that improvements could be made.

Processes had been improved since the last inspection. The management team completed daily checks to monitor wound and pressure care as well as fluid intake. Where gaps in records were observed action was taken quickly to ensure people were not placed at risk. The operations manager and the newly appointed home manager were in the process of reviewing the audit and oversight systems to ensure they were effective.