Eversley Rest Home

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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

During our assessment of this key question, we found concerns around governance and assurances systems. While the provider had systems in place to promote learning and improvement, further improvements were needed to ensure issues with the care home environment, care plans and risk assessments, managing risks, medicines management, managing incidents and accidents, and recruitment procedures were identified and addressed. Referral procedures in place to ensure people received support from health agencies were not always followed. The provider had procedures in place to ensure staff were able to support each other and promoted a caring environment. The provider had procedures in place to ensure staff felt valued and could raise any issues affecting their work. The provider had a whistleblowing policy which staff understood. The provider had procedures in place to promote staff wellbeing and worked with staff to ensure flexible working conditions.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they had a positive culture and worked well as a team. One staff member told us, “I feel like a valued member of the team. If we are busy and running late while supporting a person, we work together as a team to make sure we fit everyone's breaks in.” Another staff member told us, “Staff are really respectful towards each other and are mindful of how we talk to one another as we are all busy.”

The provider had procedures in place to ensure staff were able to support each other and promoted a caring environment.

Staff told us the management team were approachable and promoted an inclusive work environment. One staff member told us, “The manager and deputy manager are really supportive and approachable. I never worry about approaching them with anything.” Another staff member told us, “The manager’s door is always open, they promote our wellbeing and make sure we get our breaks.” Another staff member told us, “I am perfectly happy with our leaders. The manager listens to us every time and any issues are dealt with.”

The provider had procedures in place to ensure staff felt valued and could raise any issues affecting their work.

Staff understood whistleblowing procedures and felt confident the manager would act on concerns.

The provider had a whistleblowing policy which staff understood. Staff were able to report concerns in one to one meetings and the manager had an open door policy.

Staff told us they felt the managers valued and respected them, treated them fairly, and listened to their concerns. One staff member told us, “I was able to change my role when I needed more flexibility due to my own caring commitments.”

The provider had procedures in place to promote staff wellbeing and worked with staff to ensure flexible working conditions.

The management team told us they were making improvements to their systems. Staff told us they were able to make suggestions to improve the quality of care.

Governance and assurance systems in place were not effective. Environmental audits did not identify risks from trips and falls, scalding, cuts, harmful substances, and electrical wiring. This meant the provider could not be assured people were safe from the home environment. Care plan audits were not always effective. Where a person had specific health and mobility needs, conflicting and out of date information had not been identified. This meant the provider could not be assured people were supported correctly. Systems in place to monitor and mitigate people’s health risks and maintain accurate records were not effective. Where a person needed as required medication for a health need and for the GP to be informed, this was not done. Where they required support with exercises, this was not done. This meant the provider could not be assured people were receiving safe care. Medicines audits were not always effective. For example, they did not identify itopical cream not being applied for a person at certain times and omissions from stock counts. This meant the provider could not be assured medicines procedures were effective or people were receiving medications safely. Safety incidents were not always managed effectively. For example, not all recorded incidents were investigated. This meant the provider could not be assured action had been taken to prevent further incidents, leaving people at risk of harm. However, when we informed the management team about this, an updated investigation report was sent to us. Oversight of infection prevention control was not always effective. For example, there were degradation and scuffs to the environment. This meant the provider could not be assured cleaning was effective and people were not at risk from infection. Oversight of recruitment procedures was effective.

People told us the provider worked well with partner agencies in relation to their care.

While staff told us they worked well with partner agencies, the provider did not always ensure referrals were made to health agencies or safeguarding or recommendations from partner agencies were followed, where required.

We received mixed feedback from external services about how well the provider worked with them. Although some partners felt the provider responded appropriately to people’s immediate medical needs, others felt there were issues about how the provider made referrals and acted on their recommendations.

Referral procedures in place to ensure people received support from health agencies were not always followed.

Staff told us there were systems in place to ensure continuous learning such as training and checks on quality of care, and managers listened to staff suggestions about how to improve the service. The nominated individual told us they were working on a plan to improve care systems and the care home environment.

While the provider had systems in place to promote learning and improvement, further improvements were needed to ensure issues with the care home environment, care plans and risk assessments, managing risks, medicines management, managing incidents and accidents, and recruitment procedures were identified and addressed.