11 February 2023
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.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
This inspection was carried out by 3 inspectors and 2 Experts 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
Eglantine Villa Care Home 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. Eglantine Villa Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we received about the service since the last inspection. This included details about incidents the provider must notify us about, such as serious injuries. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We sought feedback from the local authority. We used all this information to plan our inspection.
During the inspection
We spoke with 10 people who used the service and 10 relatives about their experience of the care provided. We observed multiple interactions between people and staff throughout the day. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with 12 members of staff including the registered manager, regional director, nurses, care workers and support staff. We reviewed a range of records relating to peoples’ care including risk assessments, care plans and medicine records. A variety of records relating to the management of the service were reviewed including health and safety checks, meeting notes, training records, activity programmes and audits.
11 February 2023
About the service
Eglantine Villa Care Home is a care home providing accommodation with personal and nursing care for up to 49 people. The service is arranged across two units Jasmine and Lavender. Jasmine is arranged across two floors and Lavender providing care for people living with dementia is on one level. At the time of our inspection there were 47 people using the service.
People’s experience of using this service and what we found
The registered manager had created a clear person centred culture in the service with a focus on overcoming barriers to support people to achieve their goals. Staff took the time to get to know people very well and care and support was highly personalised.
Risk assessments were comprehensive and people were encourage to take risks. People told us they had choices and their preferences were respected. For example, one person told us, “I can have a bath or shower whenever I want.” Personal communication needs had been assessed and the service had implemented signage in Braille in response to this.
People, and their relatives where appropriate, were involved in decisions about their care and they received care which promoted their dignity and encouraged independence. For example one person said, “I feel independent, they allow me to do what I want to do.” Another person liked to use a wheelchair without foot plates; a risk assessment was in place for this and their wishes were respected. This enabled the person to be more mobile and independent.
People told us they could choose what to eat and said the food was good and their preferences were met. People said their rooms were personalised. One person said, “I have my own pictures up and I feel the room is my own.” Everyone spoke highly of the care workers, one person described them as “angels”.
People stayed as active as possible with a range of innovative and meaningful activities that had been planned around individual requests. People were involved in planning the activities and attended meetings to discuss ideas and things they would like to do. People were encouraged to ‘make a wish’; and staff supported them to reach their goals as far as possible.
The registered manager had promoted a positive learning culture in the service and when things went wrong, lessons were learned and shared to minimise the risk of recurrence. Effective quality assurance processes were in place to monitor the service and regular audits were undertaken to assess quality and gather feedback. Actions plans were in place where necessary following audits and these were monitored through to completion.
The service took an active role in projects for the benefit of people living in the service, to maximise the quality of care and to strive to achieve the best outcomes for people. For example, an aromatherapy project was in the planning stages during our inspection.
People had been involved in planning and delivering interactive staff training, that made them feel valued and respected. 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 and their relatives spoke highly of the management team and staff. People and their relatives knew who the manager was. One relative said, “Across the board with the staff there is good professionalism and empathy. The communication coming out under the management is very good indeed.” The registered manager actively encouraged engagement and ownership for staff and supported them to form focus groups to drive continuous improvement.
A commitment to staff wellbeing had resulted in lower staff turnover and reduced sickness. People, relatives, managers and staff worked together as a team. People, relatives and staff all said the registered manager was supportive, approachable and had an open-door policy.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk.
Rating at last inspection
The last rating for this service was outstanding (published 24 December 2019).
Why we inspected
We received concerns in relation to standards of personal care, medicines management and the environment. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe section of this full report.
The overall rating for the service remains outstanding based on the findings of this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Eglantine Villa on our website at www.cqc.org.uk.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.