Eversfield House

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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

The provider was not currently meeting a condition of their registration to have a registered manager in post. The provider was also not always submitting statutory notifications about key events as required by their registration. However, management and oversight of the service had improved. The service was led by a home manager that was knowledgeable, experienced and respected by people and staff. Governance systems were now better and a programme of regular audit had been implemented to enable the home manager to check the safety and quality of the service. People and staff were asked for their feedback about how the service could be improved. The home manager used feedback and learning to make improvements to the service. The provider was planning to improve the service further by further investment in staff and implementation of new systems to manage and administer medicines.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service was led by a manager that was knowledgeable, experienced and well-liked by people, relatives and staff. The home manager modelled inclusive and positive behaviours which motivated staff to learn and improve in their roles. A staff member told us, “[Home manager] is easily approachable. He tries to meet everyone’s needs. He is loved by the staff team and by people. He is down to earth and communicates at everyone’s level. There are no favourites. Everyone is important to him.” Another staff member said, “[Home manager] is a very caring manager. The residents really like him. He is very kind and caring. Every day he comes and visits everyone. The residents all know him and they go to him if they want something. He’s a good role model to the staff team. He is very experienced and he knows what he’s doing. I can approach him about anything. I feel it's very open here.” Another staff member told us, “When we are struggling we can ask him for his opinion and he is good at telling us how to do things the way people want. We learn from him.” The home manager supported staff to deliver high quality care and support to people. They said, “I make sure staff understand we are here to provide a service to people and this should be good quality care.”

The home manager understood the issues and priorities for the service. They had developed an action plan which set out the service’s priorities for improvements. Over the last 12 months, action had been taken to make the environment safer for people. A new electronic care records system had been implemented which meant there were now clear and current records about people and their needs and how these should be met. Comprehensive training had been provided to all staff to refresh their skills and knowledge.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The home manager had introduced a programme of regular audit to review the quality and safety of service delivery. This included auditing the environment, infection control procedures, care records and medicines management. Where improvements were identified as needed, these were addressed promptly. The home manager had also introduced a system to review and analyse any incidents or accidents that occurred to identify any patterns that may indicate an ongoing safety issue. However, the service did not have a registered manager in post. The home manager had been in role for over 12 months and at the time of this assessment we had not yet received a fully completed application from them. We discussed the reasons why with the home manager who provided assurances that an application would be submitted as soon as possible. In the meantime, this meant the provider was not currently meeting a condition of their registration to have a registered manager in post. The provider had also not always submitted statutory notifications about key events that occurred at the service as required by their CQC registration.

Staff understood their roles and responsibilities and were supported to do so by the home manager. A staff member told us, “Every time [home manager] speaks to us he makes sure we know what our roles are and to focus on people. He encourages us to do our jobs to the best of our ability.” The home manager told us about the checks they undertook to assure themself of the safety and quality of the care provided. They said, “I oversee the checks that the staff team do and make sure these are relevant. I do my daily walkarounds and do spot checks on people to see how they are being supported. I will also check equipment.”

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The home manager had learnt from the previous inspection and had made the necessary improvements. We also saw they had used reports from external agencies to inform improvements at the service. They were in the process of introducing electronic medicines administration records to further improve the safety of medicines management. Staff were supported to complete additional qualifications in health and safety to improve their knowledge and skills.

People and staff were provided regular opportunities to give their feedback and views about how the service could improve. A staff member told us, “I encourage people at residents meetings to speak up and say what they would like. [Home manager] would act on this and look to make things better for people. It is important we treat people as individuals and that we can meet their needs. People are from different backgrounds but that shouldn’t matter as they should still be treated well and looked after.” Another staff member said, “[Home manager] has asked us in meetings (for feedback) but it all seems ok. People seem happy as well. I always ask people how things are and if there is anything they need to be better.” The home manager told us they acted on feedback to make improvements people wanted. They said, “I have an open office and I will go and speak to people and find out how they are and ask if there are any issues they want to discuss and I’ll do what I can to address any issues. People want an outing and we are looking at doing this. We extended the art class from 1 hour to 2 hours based on what people wanted. We also brought in a therapy service for people and they are here today doing massage and nails.”