Eversley Rest Home

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

During our assessment of this key question, we found concerns around the safety of the care home environment. We also found concerns around the systems in place to keep people safe and how the provider managed risk. The provider did not always learn lessons when things went wrong. The provider had a system where all incidents and accidents were recorded, however some were not investigated. The provider ensured appropriate decision specific mental capacity assessments were carried out and where best interest decision making was required, the relevant people were involved and least restrictive practices were considered. Systems in place to keep people safe from the risks of the premises were not always effective. Staff recruitment procedures were effective. Although the provider was working on a plan to improve the care home environment, further improvements to the décor were needed to ensure infection prevention control practices were effective. Systems in place to manage medicines safely were not always effective.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People gave mixed feedback about how the care home learned when things go wrong. One relative told us, “The care had improved a lot since the new manager came in especially with activities for residents and the cleanliness of the care home.” Another relative told us, “When we have raised issues with care or have asked for things to be put in place, it has taken a long time for things to improve or to be put in place.”

Staff told us there was a culture of learning at the care home. One staff member told us, “Managers do spot checks with us and make sure we are delivering safe care and that we are wearing the right personal protective equipment (PPE).” Another staff member told us, “We complete staff surveys and hold relatives’ meetings and management act on suggestions. When incidents happen, we investigate what went wrong and discuss the learning in staff meetings. We also have regular one to one meetings with a senior colleague.” Another staff member told us, “The managers want people to participate in activities and have recently purchased technology which has interactive and reminiscence activities.”

The provider did not always learn lessons when things went wrong. There were systems in place to identify when things went wrong however the provider could not evidence all incidents were investigated. Although the provider had an improvement plan and maintenance action plan in place to improve the premises, environmental checks did not always identify risks in the care home environment. This meant the provider could not be assured improvements were being made where required. Staff could make suggestions on improving care through team and one to one meetings and staff surveys; and relatives could raise any concerns or make suggestions through relatives’ meetings and surveys and management acted on these.

People told us they received safe care. One relative told us, “I know my [relative] is safe and receives good care because they are eating and drinking well and are settled.” Another relative told us, “When my [relative] was poorly, staff were quick to respond and made sure they went to hospital. The director even visited them in hospital and reassured them they would get her back to health and that was indeed the case.” While people told us they were safe, the provider did not always ensure care plans were accurate or referrals were made to health agencies or safeguarding, where required.

Staff told us people received safe care. One staff member told us, “If a resident is unusually quiet or doesn’t seem themselves, we raise it directly with a senior who contacts the GP, district nurses or other health professionals.” Another staff member told us, “A resident we are supporting has a problem with their skin and we are working closely with the district nursing team and following their recommendations. We help them to change position regularly, and the skin is improving.” While staff told us people received safe care, the provider did not always ensure care plans were accurate, referrals were made to health agencies or safeguarding, where required.

We received mixed feedback, from professionals visiting the care home, about how people were cared for. One professional told us, “Staff know their patients, identify health issues appropriately and have done what is required of them before we visit.” Another professional told us, “There have been issues with the provider following the referral process which risks people not being seen by our service in a timely way. The provider have not always followed our recommendations in a timely way.”

Systems in place to keep people safe were not always effective. Although care plans included information about people’s health and guided staff how to escalate concerns, this did not always lead to referrals to health agencies when required. Although the provider worked with health and social care agencies, their recommendations had not always been followed by the provider. Where accidents and incidents were recorded and indicated safeguarding concerns, these were not always referred to the local authority in a timely way. During our assessment when a person became unwell, staff identified symptoms of a stroke and acted quickly by calling for an ambulance. Staff liaised with the first responders, provided them with the person’s social and medical history and followed their recommendations.

Although the people we spoke to had not felt the need to raise safeguarding issues, they reported they felt safe and well cared for. One person told us, “I like living here and the staff are very caring.” Another person told us, “The staff are lovely."

Staff understood safeguarding procedures and whistle blowing. They explained they had undertaken training about abuse and knew how to recognise and report this. One staff member told us, “I have done my annual safeguarding training and know how to follow safeguarding procedures.” Another staff member told us, “I would report any safeguarding concerns to a senior who would then inform the manager. I have never had to raise any safeguarding issues as all the staff are caring.” Staff understood the Mental capacity Act 2005 and how to include people in decisions about themselves. One staff member told us, “We should never assume people don’t know things and we include them in decisions about how to support them.” Another staff member told us, “When a person had a fall and a low bed and crash mat was put in place, we were conscious of how this deprived them of their liberty and followed deprivation of liberty safeguards (DoLS) procedures.”

While we did not observe any incidents requiring a safeguarding response, we observed staff following least restrictive principles. For example, one staff member supported a person with mobility needs to sit and stand safely by guiding them and explaining the location of the chair and mobility aid. This was done using a respectful and compassionate approach while understanding what the person was able to do for themselves.

The provider had a system where all incidents and accidents were recorded, however some were not investigated. For example, where a person was recorded to have hit another person living at the care home, this was not investigated at the time. This meant the provider could not be assured lessons were being learned or safeguarding issues were being identified. When we told the provider about this, they made a referral to the local safeguarding team straight away. The safeguarding policy had been reviewed and was up-to-date. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguarding (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met. The provider ensured appropriate decision specific mental capacity assessments were carried out and where best interest decision making was required, the relevant people were involved and least restrictive practices were considered. Applications were being submitted appropriately when DoLS authorisations were needed.

People told us they were included in managing their risks and staff supported them well. One relative told us, “When [relative] has had a fall or becomes unwell, staff get in touch”. Another relative told us, “[Relative] is eating well, has put on weight and looks healthier for it.”

Staff told us they knew people’s risks and when to escalate concerns. One staff member told us, “If [person] was disorientated and upset, I would give the them space and use distraction techniques. I would use a softer voice and give reassurance.” Another staff member told us, “We help people with their mobility risks but if somebody does have a fall, we press the buzzer and call for help. We make them comfortable, ring family and call for an ambulance if needed.”

We observed staff supporting people’s risks in line with their care plans and risk assessments. Where one person had eating and drinking needs, food was served to the correct consistency and staff ensured the person had swallowed and offered a drink before supporting with the next mouthful. We observed where people required equipment to relieve skin pressure such as pressure cushions or mattresses, these were in place.

Systems in place to manage people’s risks were not always effective and staff did not always follow guidance in people’s care plans. Care plans and risk assessments did not always contain consistent, up to date and accurate information. For example, one person’s care plan included conflicting information about how they were supported with their mobility and out of date information about their health needs. This meant the person was at risk of receiving unsafe care. Although staff were monitoring a person’s health need, staff did not administer as and when medication or contact the GP when required as instructed in with their care plan. This meant the person was at risk of not having their health need met. Where a care plan included recommendations from a health agency about how to support a person to recover from an injury, there were no records to indicate staff had supported them as recommended. This meant the person was at risk of a delayed recovery. People had personal emergency evacuation plans in place.

People gave mixed feedback about the care home environment. One relative told us, “There are little things that can be improved. There have been problems with heating and mould in my [relative’s] room.” Another relative told us, “There are some issues with the building such as the condition of the windows, but the managers seem to be getting on with sorting things out.”

The nominated individual told us they were working on a plan to improve the care home environment as they had identified issues with the building such as needing to replace exposed pipes and to renovate rooms.

People were at the risk of harm as the provider failed to ensure the physical environment was safe for people to live in. We found some rooms with environmental hazards were not secure. For example, the kitchen, which contained pans with boiling water and kitchen knives on shelves, was left unlocked and unsupervised. This meant people were at risk from scalds and cuts. Other rooms which contained trip hazards, harmful substances or access to electrical wiring were left unlocked and unsupervised. Some rooms which contained, trip hazards and harmful substances or access to a staircase were locked however could be accessed by a key located on hooks next to the entrance doors. This meant people were at risk from trips, falls from height, exposure to harmful substances and electrical injuries. A cupboard containing information about people’s skin and bowel conditions and how they were monitored, was left unlocked and unsupervised. This meant people’s personal information could be accessed by others including other people and visitors to the service. When we told the management team about the environmental issues we found, they started to address them straight away.

Systems in place to keep people safe from the risks of the premises were not always effective. Although environmental audits took place to monitor the safety of moving and handling equipment, electrical items, window restrictors and call bells, monthly communal area audits and daily walk arounds did not identify all risks from the care home environment. Routine testing took place for fire alarms and evacuation procedures. Environmental risk assessments were in place such as fire safety, gas safety and water safety. These were up to date and where there were issues identified, these had been addressed or there was a plan in place to address them.

People told us they felt safe with supportive staff. One relative told us, “Although [relative] has complex needs due their dementia, staff are caring, and they feel safe.”

Staff told us they had had their required training and delivered safe care. One staff member told us, “I am always on training and my safeguarding training is refreshed annually. We have daily handovers and regular team and one to one meetings where we are kept up to date with people’s needs.” Another staff member told us, “The list of training I have done is extensive including Mental Capacity Act training, dementia, and end of life care. I know the residents and what things they like to do.” Another staff member told us, “Shifts flow well as we have a good balance of staff, and the work is split fairly.”

We found there was enough staff available, and staff delivered safe and compassionate care which met people’s needs.

Staff recruitment procedures were effective. New staff were subject to DBS checks. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions. Staff had received their required training which was refreshed annually. Team meetings, one to one meetings and daily handovers were in place to support staff to provide safe care to people. There were enough staff, and the provider had recently increased staffing in line with an increase in the number of people living at the care home.

People told us the home environment was clean. One relative told us, “The environment is a lot cleaner now and smells clean since the new manager arrived.”

Staff told us they understood about good infection prevention and control. One staff member told us, “The care home is clean. Staff wear aprons, gloves and hairnets where required and we understand how to don and doff our PPE (personal protective equipment).”

Although we observed domestic staff cleaning the premises, we observed degradation and scuffs to the environment such as wallpaper and on doors. This meant that cleaning could not be carried out effectively and people were at risk from infection. Staff used personal protective equipment (PPE) during mealtimes. Information about how to reduce the risk of infection was displayed on posters throughout the premises.

Although the provider was working on a plan to improve the care home environment, further improvements to the décor were needed to ensure infection prevention control practices were effective. Infection prevention control substances were not always secured safely. This meant people were at risk from exposure to harmful substances. Staff understood about good infection prevention and control. They had training to help them understand this and followed good hand hygiene practices. There was enough personal protective equipment (PPE) available, and staff knew how and when to use this. The infection prevention control policy had been reviewed and was up to date.

The people we spoke to had no concerns about how they were supported to receive their medication.

Staff responsible for administering medication told us they had received their medication training, learned from incidents, and felt confident people received their medication safely. One staff member told us, “My medication training is kept up to date. We keep medications locked away and discard medications in line with our medication policy. Another staff member told us, “We audit medication practices. When medication errors occur, they are investigated, and we put things in place to reduce the risk of repeated errors.”

Systems in place to manage medicines safely were not always effective. As and when medication was not always given to meet a health need in line with people’s care plans. Where staff had been recording a person not being given their topical cream for a prolonged period, they had not informed the GP. This meant people were at risk of not having their health needs met. However when we informed the management team, they contacted the pharmacy and put a plan in place to ensure the topical cream was applied consistently. Medications were not always included in stock counts. However, when we counted these medications during our assessment, we found the amount of stock was correct and there was no impact on people. Medicine Administration Records (MAR) were completed, and medication audits took place. Errors were investigated and measures were put in place to reduce the risk people coming to harm.