Archived: Eversley Nursing Home

Updated 13 February 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of the CQC response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This inspection took place on 28 January 2021 and was an announced, targeted inspection looking at the infection control and prevention measures the provider has in place and seeking to identify examples of good practice.

Updated 13 February 2021

Eversley Nursing Home provides accommodation, nursing, and personal care for up to 18 people. The service specialises in providing palliative and end of life care. On the day of our inspection, there were 18 people living in the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The last inspection took place on 30 September 2015, and the service was assessed as being 'good' in all domain areas and had a rating of 'good' overall.

At this inspection we found standards had been sustained and again rated the service as 'Good' overall.

There were clear lines of accountability. The service had effective leadership and direction from the registered manager who was passionate about providing a high standard of care. The visions and values of the service were embedded into practice and the management team promoted best practice to make further improvements. Partnership working was excellent, for example, working with health care professionals which had been sustained over time.

Staff spoke positively about the registered manager, stating they were approachable, caring and responsive to people's and staff's needs. Involvement through partnership working was sought and guidance implemented within people's care and service delivery.

The service liaised well with external healthcare professionals and people's healthcare needs were being met. A high standard of end of life care was provided; the service had been awarded a ’beacon status’ for the Gold Standard Framework in relation to this.

People were treated with a high level of dignity and respect by both staff and the management team. Staff were patient with people, and skilled in using different methods of communication which reassured people. Good, caring relationships had been developed and staff and the registered manager knew people well. There was a positive, inclusive and person centred culture within the home.

Staff were given regular training updates, supervision and development opportunities. People spoke positively about staff and the support they received. Staff demonstrated a good knowledge of the people and topics we asked them about.

People received their medicines in line with good practice and staff had sufficient knowledge on how to administer, record and dispose of people's medicines safely.

People had access to a range of suitably nutritious food. Individual preferences were catered for. People's nutrition was closely monitored and action taken to investigate any weight loss.

People told us they felt safe and secure living in the home. Staff understood people well and knew how to keep them safe. Risk assessments were in place which provided detailed information to staff on how to maintain people's safety.

Staff were able to recognise abuse and knew how to report concerns if they suspected a person was being abused. Systems were in place to discuss potential safeguarding issues so they were escalated appropriately.

There was a complaints procedure available in the service for people and relatives to raise concerns.

Staffing levels were calculated using a dependency tool, and we observed that people were attended to regularly. Some people told us that would like to see more staff and sometimes felt lonely. The provider and staff members confirmed that additional staffing was brought in where needed, or in the case that a person deteriorated suddenly.

Activity provision was delivered in the form of Namaste care. This is undertaken on a one to one basis, and can include but is not limited to, musical reminiscence, talking, looking at photos, or massage. People can chose how they spend the time, and what they find meaningful. Some people felt that they would like more of this, and a representative of the provider told us that they had increased the provision to now include weekends.

People's consent was gained before care and support was provided. The service was acting within the legal framework of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Some areas of documentation relating to MCA assessments required improvement, but the registered manager was taking prompt action to rectify this.