Eglantine Villa Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The provider had a process in place to ensure lessons were learned across the organisation when incidents and accidents occurred.

We saw that lessons were also learned on local level in the service when issues occurred. For example, following a choking incident in 2024, significant changes had been made to the preparation of food and support with eating for people who had been assessed as requiring a modified diet. Additional signage had been placed around the service, on people’s doors (in a discreet place) and additional training had taken place. A staff member told us, “We discussed lessons learnt from the choking incident and food. We did enhanced training. Communication from lessons learnt was good.” Most relatives told us they were made aware of incidents and accidents when they happened. A relative gave an example of changes made to their loved one’s care and support following a fall. They explained that different equipment was put in place to keep their loved one safer. People told us they felt safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. When people were supported to go to hospital, either through routine or planned admission, emergency admission or consultation day visit, support was in place as well as hospital passports. A hospital passport helps people to give hospital staff important information about them and their health when they go to hospital. A relative told us their loved one always went into hospital with their hospital passport. They told us that once it had not been updated appropriately which resulted in their loved one receiving incorrect care and treatment. This had since been rectified and has not happened since.

People were supported to maintain their health, attend appointments both inside and outside of the service. Where routine health checks were undertaken people had support from people who they know well to understand what was happening. The service had maintained regular contact with local authority social workers. This included good ongoing work with the GP and other health and social care professionals. Staff told us they were able to contact the GP. The registered manager told us, “Dr Shetty comes in every Friday for a physical ward round, reviews people we’ve added to list. We are very well supported by the GP. In between times we email the surgery, and they come back to us before the end of the day. We are lucky to have a physical support.” A relative said, “Mum has seen the GP when needed, she has deteriorated, and they are aware of that.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People were safe and were protected from harm. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. Safeguarding policies included information about safeguarding children from abuse. Safeguarding training included safeguarding children. This is because staff in care services come into contact with children as part of their work. The management team had reviewed processes and learnt lessons from safeguarding incidents.

We observed interactions between staff and people during our visit. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff were similarly aware of whistleblowing and were confident to speak up if needed. A staff member said, “I have done safeguarding training, if someone reported abuse, I would report to [the deputy manager and the registered manager]. It would be dealt with.”

The provider worked with people to understand and manage risks by thinking holistically. However, staff did not always provide care to meet people’s needs that was safe. We observed that risks were not always well managed. We observed a person sat in their chair in their room without their falls sensor mat in front of their chair. Their care plan and risk assessments stated that this should be in place when they were seated in their chair or when they were in their bed. This was rectified by nursing staff to prevent any harm.

Risks to people in relation to harm from constipation were not always well managed. For example, action had not always been taken to give people as and when required laxative medicine according to their risk assessment and care plan. Such as when they had not opened their bowels for more than 48 hours. We found some cases where this has exceeded the time limit, and no action had been taken.

Risk assessments were inconsistent. For example, some were detailed and provided clear guidance to staff about how to work with people safely. Others were vague and did not give clear guidance. For example, 1 person’s falls care plan and risk assessment stated they had a chair sensor in place and that staff were required to check that it was at the correct setting and it’s in correct position. However, staff had no information about what the required position was.

Relatives told us that changes had been made following incidents and accidents and risks were reviewed. People told us they felt safe. Staff told us changes to risk assessments were shared across the team. Staff had a good awareness of most people’s risks, and we saw them supporting people to sit up more to eat and drink and checking that pressure relieving equipment such as heel protectors were in place. Personal emergency evacuation plans (PEEPs) were in place in the service to detail people’s support needs if they required to be evacuated in an emergency. People were supported to move around the service safely and were supported to spend time where they chose. People were given food and fluid in a consistency which was in accordance with their assessed needs (including diabetic diets). The food was well presented, and people seemed to be enjoying the experience. Staff told us about safe ways of working with people which demonstrated they knew them well.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Staff had been trained in health and safety and fire awareness and were able to tell us about the fire procedure that was in place and how to evacuate people safely in the event of an emergency. Regular checks of the alarm system and firefighting equipment took place. We observed some corridors had hoisting equipment parked in them which restricted the size of the corridor. The registered manager told us there was nowhere else these could be stored as these were in parts of the service which required a stair lift and the hoist could not be moved on the lift. The fire service had inspected the service, and the provider had carried out a fire assessment, a number of actions had been added to an action plan and contractors were on site addressing these.

Most maintenance tasks had been completed in a timely manner. A person had been injured due to problem with a shower door 2 weeks prior to the assessment site visit. The shower door was due to be replaced whilst the assessment was taking place. Planned maintenance was in progress. The maintenance team told us that the provider and registered manager enabled them to carry out repairs and general maintenance and there was a clear budget for this. Rooms were clean and tidy and had been personalised in accordance with the person’s wishes. The provider had systems and processes in place to detect and control potential risks in the care environment. This made sure that the equipment, facilities and technology supported the delivery of safe care.

Essential servicing and maintenance of the service, utilities and equipment had taken place. The maintenance team told us they carried out daily checks of the service including people’s rooms, they then completed any maintenance jobs that were needed. Relatives told us that the service and grounds were well maintained. People’s requests for repairs were dealt with quickly. We observed one person asking for maintenance to attend their room as they were unable to get any channels on their television. This request was immediately dealt with.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. We observed there were enough staff on duty to support people during the day but not at nighttime. Rota records mapped against people’s emergency evacuation needs showed there were not enough staff at night to safely evacuate people if needed, one person required 6 staff members to evacuate them to a place of safety and there were only 3 staff on duty in this part of the service. The registered manager said staff could be taken from the other unit to support with evacuation. However, this would mean that that unit would not have sufficient staff to keep people safe. Meeting records with night staff showed that staff had raised staffing concerns in November 2024 and the management team agreed to review and address this. The registered manager told us that staffing levels had been reviewed and a twilight shift had been identified as being required to support the night staff. The registered manager told us the staffing levels had not been adjusted since this was raised as they had not received interest in the advertised vacancy for a twilight shift pattern.

We observed call bells were answered quickly. People told us there were enough staff. Comments included, “I never feel I’m waiting very long”; “They are around and at night they do a regular walk around”, “I have used the call bell 1 or 2 times at night, they answered quickly” and “There are always staff available to help.”

Staff had been safely recruited. All required checks had been carried out and documents were all in date. The information helps employers make safer recruitment decisions. Nurses were registered with the Nursing and Midwifery Council. The provider had made checks on their personal identification number, registration status and renewal date.

Staff had regular supervision meetings, induction was a mixture of training and shadowing experienced staff to gain confidence and experience. The training matrix showed that most staff had completed mandatory training. Staff told us “The training here is excellent. When I started, I thought I knew a lot about care work from my previous job, but I've learned so much more. We regularly update our skills, and there's always someone to ask if you're unsure about anything” and “They are good about giving extra training, I wanted support with venepuncture [carrying out blood tests] and chronic wounds and this was given.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The provider had systems and processes in place to assess and manage the risk of infection. The provider had a daily cleaning programme in place. The service employed housekeeping staff to carry out daily cleaning, cleaning schedules were in place which included deep cleans for people’s rooms. Infection control audits were completed regularly and actions taken if any issues were found. The provider had plenty of PPE (Personal protective equipment) in place to keep people and staff safe. The kitchen areas were clean and well managed.

We observed that the staff were using PPE effectively and safely. We were assured that the provider was promoting safety through the layout and hygiene practices of the premises. There were no restrictions to visitors. We observed visitors coming and going freely during the assessment.

Staff told us they had sufficient equipment and PPE to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. A staff member told us, “Infection control can’t be over-emphasised, it’s so easy to spread infection especially in a care home as people are so frail and vulnerable. A cough for me resolves quickly, but for the residents here, it may need antibiotics. We have domestic staff that routinely clean but it’s up to everyone to keep their eyes open and do what they can.” Relatives told us, “It is always clean and well kept” and “There are no complaints about the cleanliness of the home.” People told us the service was clean. A person said, “It's clean, my bed is changed practically every day.” Another person said, “The home is spotless, you can’t fault it.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. The provider had systems and processes in place to manage medicines. Some improvements were identified. We identified that stock counts of people’s medicines did not always balance with the records held in the service. This meant there were medicines that were unaccounted for, and the provider could not be assured people had their medicines as prescribed. During the assessment we identified that a person had only been given half a dose of their epilepsy medicine. This was identified during our stock counts with the registered nurse. They appropriately reported this to the management team and sought advice from the GP in relation to the person’s next dose.

Some people had gone without medicines and experienced delays in receiving their medicines due to issues with medicines not being received. This meant people had gone without prescribed medicines for days, which had the potential to impact on their health. Nursing staff had contacted the GP and pharmacy to chase these missing medicines. In some cases, this was because there were some delays to medicines being booked in, which meant there were delays in recognising the medicines were not in place for the new cycle starting on a Monday. If the booking in of the medicines did not happen until the weekend there was no one available at the GP surgery to escalate the concerns in time for the medicines to be in place on a Monday. Actions had not been taken to arrange emergency prescriptions of medicines from 111. We discussed this with the management team, who agreed to review the practice and to meet with the GP practice manager to look at ways to improve the communication. After the assessment the registered manager fed back that improvements had been made to the booking in process for medicines and people were no longer experiencing delays in receiving their medicines.

Despite the evidence above, people gave us positive view about their medicines support. Comments included, “They give me my medication, and it is when I need it”; “There is a regular medicines person, day and night and they give me my medication” and “I self-medicate and they order it all for me.” Relatives told us, “They are pretty good with his medicines. They always call to discuss medicines” and “They keep medication going and she has patches for the pain; they keep on top of it.” Staff told us they had medicines training and were competency assessed. A staff member said, “There are competency assessments every 6 to 12 months for administration of medicines and moving and handling.”

The management team carried out regular medicine audits. People received their medicines from trained staff. The staff informed us they received training and were competency assessed to handle medicines safely