Eversleigh Nursing Home

“The provider did not always demonstrate effective governance systems to promptly manage the safety of the environment and other risks to people. Improvements were also required to the way people’s medicines were managed. This placed people at risk of harm. We found the provider was in breach of the legal regulations relating to safety, premises and equipment and governance.”

“Processes to make sure people received their medicines safely were not working well. We found some medicines stocks held did not agree with people’s medicines administration records. We could not therefore be assured people had received the correct amounts of medicines they needed to remain well. The registered manager told us they were not involved in medicines management or checks. Senior staff said they were not aware of the issues we found but agreed to rectify them with staff.”

“During this assessment we spoke with people who lived at the service, care and nursing staff, a maintenance person, the registered manager and a provider representative. We reviewed care plans, recruitment files, health and safety records, medicines administration records and quality assurance records. There had been changes in the day to day management team but the registered manager had been at this service since November 2022.”

“The provider’s quality assurance systems were not effective in identifying and rectifying shortfalls in day-to-day practice. Where checks were delegated to others, there was limited oversight to ensure those checks were completed or that they were accurate. A lack of effective checks on the environment and prompt completion of actions identified exposed people to unnecessary risks. This included in relation to fire doors which in some cases closed too fast and could cause the risk of entrapment. We found other fire doors did not close properly. Although some regular environment checks were completed, evidence from our own observations showed there remained a lack of consideration to balance and manage risks, with some risks having a negative impact on infection prevention and control.”

“Senior staff administered people their medicines, but we found some medicines were not administered in line with manufacturers guidelines. This included medicines applied via a transdermal patches, (medicines applied to the skin via a patch). Senior staff found the electronic medicines management system difficult to operate and the medicines management system did not enable staff to easily find the information we required. We found medicine stock discrepancies had sometimes been amended without any proper investigation to understand why stocks did not balance. Senior staff told us they had checks on their competency to ensure they administered medicines safely and medicines audits were completed monthly. However, the issues we found had not been identified by the registered manager. We could not be confident some people received their medicines safely.”

“We found concerns with infection prevention and control, which were linked to the environment and there were delays in people’s requests for assistance being responded to. People’s care plans did not always provide staff with the level of detail they required to promote person-centred care. Improvements were required in staff practice when interacting with people, to ensure people’s dignity was promoted. People’s mental capacity assessments…”