Eglantine Villa Care Home

On this page

• 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.At our last assessment we rated this key question outstanding. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 82 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. Information about the vision, strategy and culture was available around the service for people, relatives, visitors and staff. The provider and management team were passionate about the service and wanted to ensure people had good quality care and improved outcomes. Bupa vision and values state ‘Our purpose is to help people live longer, healthier, happier lives, and making a better world.’

The staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Comments included, “It’s very good here. This feels like home. I have recently had [time] off, and I missed this place so much, not just the girls (staff), but the residents too. It’s an environment where you can make mistakes knowing you’ll be supported. You can always ask for assistance” and “We have handover every morning, monthly staff meetings where we are asked for any suggestions because we are working directly with people every day. Where we try to improve the most is in the communication and interaction with the residents, suggesting activities. For example, one lady loves owls, so we had owls come here. We had to keep the lady who hates owls far away and occupied. Team meetings are in Jasmine [dementia unit], we are notified in advance; they are about what’s going right, what’s not going so well, given the opportunity to give our feedback.”

The provider had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty. There continued to be a clear management structure, nurses and care staff understood their responsibilities to meet regulatory requirements. The registered manager was supported by an area manager who visited the service regularly to undertake checks and audits. The management team told us they were well supported by the provider. The registered manager continued to meet daily with heads of departments to ensure key messages about people were shared in a timely way. Daily handover meetings were held so staff had up to date information about the people they were supporting. Staff told us the management team were supportive and approachable and were confident in reporting any concerns. The provider had a ‘Love Working Here’ network, they had engagement champions to ensure staff experiences were fed back and initiatives to improve were then cascaded to staff across the provider’s business.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were assured that all incidents had been appropriately reported.

Staff told us Eglantine Villa was a good place to work. Comments included, “The manager and deputy are always there to support us and are always on the floor, helping us or if we are feeling anxious about anything. I do feel supported in my role” and “I have been here 2 years and it’s the best decision to be here. I love it, it is like a family.” A relative told us, “The staff and management are very accessible. I have had no need to complain about anything. The staff are easy to talk to and have great empathy for dad. Many staff have been at the service for years which I think is a good sign that the company is good to work for.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Complaints processes were available. People told us, “The manager has helped me in the past. I’m sure she would in the future”; “The manager is always around and if you need to talk to her, you can arrange a time to” and “I know her, and she helped me with an issue I had and I was happy with the outcome.” Relatives confirmed the registered manager was responsive and accessible and had followed up any concerns or issues they had, most relatives were satisfied with the response. A complaint was ongoing, and relatives had escalated this to the local government ombudsman as they were not satisfied with the response they had received. Staff confirmed they were invited to meetings and encouraged to contribute. They felt listened to. Staff meeting minutes evidenced that these took place regularly. Staff told us they were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to, following the provider's whistleblowing process. The provider had a See Tell Act Report (STAR) process in place and posters were on display around the service prompting people and staff to report any concerns.The STAR process promotes speaking up, safeguarding, learning lessons and being responsive to people's needs. The registered manager told us, "We created a one page document to remind staff of the initiative and importance of acting and this is revisited in staff meetings, huddles and handovers as well as [the] newsletter."

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them. Staff told us they were treated very well and supported equally by the management team and provider. The provider had processes in place to encourage an inclusive culture. A detailed notice board was in place to provide information for people, relatives and staff about equality and diversity. It provided information about language, religion, accessible information standard, and about LGBT (lesbian, gay, bisexual and transgender). The provider also had a ‘Be You Network’. The aim of the network is to raise awareness of inclusion and diversity issues and serve as a consultative forum on Bupa’s inclusion strategy. The Be You Network provide peer support to staff to enable them to bring their whole selves to work. The workforce was diverse, and support was in place for staff. Any issues could be discussed openly at staff meetings or during supervision.

The registered manager had an open-door policy and staff told us they would not hesitate to speak to the registered manager if they needed to. Staff reported the staff all worked together well as a team. Staff told us, “If no carers are around, nurses and seniors help out. [Registered manager] does also step in and help, she is very good. She is very present on the floors, she knows residents very well”, “I've worked in several care homes, but this is the first place where I feel the management really cares about both staff and residents. They're always asking for our input on how to improve things. I am happy that my manager listens to me” and “[Registered manager] will share good practice and lessons learned from other Bupa services and she listens to us. For example, a member of staff raised what improvements could be made in the garden.” The registered manager ensured staff with protected characteristics were supported with any reasonable adjustments if required. For example, breaktimes had been scheduled around times of prayer for staff celebrating certain religious festivals.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Audits had been carried out. There were audits of infection control, care plans, medicines, call bells, falls and wounds, incidents and accidents, health and safety, fire, dignity and mealtime experience. Action plans were developed to address any shortfalls. Outstanding actions were reviewed and updated each month. Audit results and outcomes were reviewed by regional directors. However, the audits were not always robust enough to highlight and manage shortfalls and areas for improvement in the service. For example, the audits had not picked up that feedback from night staff had not been actioned. The provider had undertaken a listening event with night staff who also told the provider there was not enough staff at night, but action had not been taken to increase the staffing levels. Audit systems had not always identified the inconsistencies in risk management in relation to use of equipment and constipation nor had it been detected that records relating to repositioning and fluid intake were not robust. Since our site visit the registered manager informed us that these issues have been discussed with staff at group meetings to press the importance of accurate recording and ensuring care plans and risk assessments are consistent and reflect people’s needs.

The registered manager provided information about how the service was improving environmental sustainability. Dual recycling bins had been purchased for the service, They had also signed up to a battery recycling and printer ink cartridge recycling service. The service was exploring other recycling services and staff had been recruited as sustainability champions to help drive change within the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Information was shared with staff in monthly newsletters which included learning from the organisation. The management team and staff worked hard to build and maintain relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people. The service had developed partnerships with varied organisations and the local community through activities, end of life care, the local authority and through good links with GPs.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The registered manager told us they had reviewed the feedback we gave them as part of the assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes. Areas discussed at the assessment site visit were added to the action plan for the organisation in a timely manner and the registered manager updated CQC on the progress of these actions.

Staff meetings were scheduled and held to discuss feedback and embed learning and improvement to benefit the people living at the service. The provider and the service had provided regular feedback to staff about lessons learned. The registered manager also completed a lessons learned review on a quarterly basis which was shared with staff to ensure a learning and improvement culture.The registered manager told us, “We are committed to always ensuring lessons are learnt to maintain a safe environment for our residents.” The registered manager also told us, “In response to feedback around a lack of documented oral care, we have added this to planned care for all residents who need support. We already have an oral care champion who focuses on identifying residents with poor or declining oral health (including well-fitting dentures, teeth and gum health etc) and liaises with seniors and nurses to make community dental referrals. The oral care champion also helps to identify and share tips and coping strategies for residents that may resist mouth care to help colleagues. However, based on this feedback the oral care champion alongside senior managers will review oral care charts/documentation weekly and feedback to colleagues on areas of improvement. We have also began rolling out a ‘Mouth Matters’ competency for all relevant roles."