Eversley

Updated 16 February 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was carried out by 1 inspector and 1 Expert by Experience. (An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.)

Service and service type

Eversley is a 'care home.' People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

The service did not have a registered manager in place.

Notice of inspection

This inspection was unannounced for day two and short notice was given for day one of this inspection to ensure people would be at the service.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with what they do well, and improvements they plan to make. This information helps support our inspections. We used this information to plan our inspection.

During the inspection

We spoke with 4 relatives and 4 people living at the home about their experience of the support provided. We spoke with 6 staff that included the home manager and area manager.

We reviewed a range of records. This included 3 people's care records and multiple medication records. We looked at 3 staff files in relation to recruitment and staff supervision and a variety of records relating

to the management of the service, including policies and procedures.

After the inspection

We continued to seek clarification from the provider to validate evidence found during the inspection and the evidence provided after the site visit.

Updated 16 February 2024

About the service

Eversley is registered to provide accommodation with personal care needs to eight people who have a learning disability or autistic spectrum disorder. There were 7 people living at Eversley at the time of this inspection.

People's experience of using this service and what we found

There were a number of outstanding fire risks and repairs needed for the environment, such as a fire risk assessment identifying risks needing attention to improve fire safety.

The garden areas were in need of maintenance to help improve and enhance living areas for people.

Auditing of the service had not identified appropriate actions to show improvements to managing supervision of staff, improve training uptake of necessary topics and management of each person's one to one hours. Staff had not heard of CQC 's publication, 'Right are, right support, right culture.' The area manager and home manager were responsive and by day two of this inspection had taken some actions to manage training, supervision and responded to fire risks.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessment and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

People received care and support that was tailored to their individual needs and wishes. People and their relatives were actively involved in planning and reviewing their care plans. People and relatives shared very positive comments about the staff and the support they received. Staff knew people well and were responsive to changes in their needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People had the necessary capacity assessments and legal processes in place to ensure their rights were fully respected

People continued to receive care and support that protected them from the risk of harm and abuse. Staff knew how to recognise and report the signs of abuse and poor practice.

Staff monitored people's health and supported them to access and follow healthcare advice. People received their medicines as prescribed and accurate records were maintained.

Rating at last inspection

The last rating for this service was rate good published (27/9/2017). The service has been rated requires improvement at this inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We undertook a focused inspection to review the key questions of safe and well-led only. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Eversley on our website at www.cqc.org.uk

Enforcement

We have identified a breach of the regulations in relation to lack of effective governance of the service and safe care and treatment.

Please see the action we have told the provider to take at the end of this report.

Follow up

Will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect the service.