Background to this inspection
Updated
9 July 2022
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 completed by one inspector.
Service and service type
Villcare Ltd Eastbury Road 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. Villcare Ltd Eastbury Road is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
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. At the time of our inspection there was a registered manager in post.
Notice of inspection
We gave an hours’ notice as the home was small supporting two people and we wanted to check if a member of staff would be available to let us in.
Inspection activity started on 26 April 2022 and ended on 12 May 2022. We visited the home on 26 April 2022 and 6 May 2022.
What we did before the inspection
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 spoke with the local authority to gain their views of the home and we reviewed the records we hold. We used all this information to plan our inspection.
During the inspection
We spoke with one person's relative about their experience of the care provided. People who used the service who were unable to talk with us and used different ways of communicating such as body language and pictures. We spent lots of time seeing how staff supported people in their day to day lives at the home.
We spoke with four members of staff, the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We looked at a series of documents on each visit to the home. Staff recruitment files, fire safety checks, risk assessments, care plans, incident forms, meetings notes, and medicines records. We requested further documents such as audits, risk assessments, care plans, daily notes and emergency plans to be sent to us electronically.
After the inspection
We continued to seek clarification from the provider to validate evidence found.
Updated
9 July 2022
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 assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
About the service
Villcare Ltd Eastbury Road is a care home providing personal care to two people. The home is a bungalow with a garden and access to the local town. Most people who were living at Villcare Ltd Eastbury Road had a physical and learning disabilities, including autistic people. The home can support up to four people.
People’s experience of using this service and what we found
Right Support
¿ People had not gone out since lock down ended to pursue their interests and do things they enjoyed. Plans and strategies had not been made to promote this part of people’s well-being and to explore their interests.
¿ People received their medicines as prescribed. But staff did not have training on how to administer one person’s medicine. Nor had this person been consulted with and involved in the plans of how this would happen.
¿ Meetings took place with people about their support and care. But these did not cover all aspects of their care, their goals and aspirations. The records of these meetings were not in formats people themselves could understand.
Right Care
¿ The physical environment of the home looked tired and in need of redecoration. Spaces in the home were not personalised, this included people’s bedrooms. Most of the living rooms had information for staff to read and look at, like you may expect to see in a staff room. Plans had not been made to help people to utilise and enjoy their home and garden.
¿ Staff were polite with people and they checked they were okay. However, staff did not speak with people in a social way or help them follow their interests.
¿ There were gaps in staff’s knowledge in terms of promoting people’s safety from experiencing potential abuse and harm. Understanding the risks people faced and responding to a potential fire.
¿ The registered manager had ensured various building safety checks had been completed. There were enough staff to meet peoples care needs.
Right Culture
¿ The leadership of the home had not empowered people to have ownership of their home. The culture was not fully person centred and failed to focus on the individual, their interests or advocate on their behalf when necessary.
¿ When new people came to stay at the home, people were not consulted with in a meaningful way, to see if they were happy about this. We also found shortfalls when a new person came to stay at the home in terms of assessing risks and making plans to support them and others to be safe.
¿ The provider and registered manager’s audits to check the quality of care provided were not effective in relation to monitoring the standard of care people received, responding to incidents and changes in need and considering if people had full risk assessments and plans for staff to follow.
¿ The service lacked pro-active leadership. The provider and registered manager did not keep up with changes to regulatory expectations and development of best practice standards. They failed to assess people’s experiences to see if improvements to practice and systems could be made.
¿ People were not being given opportunities small or large to promote their interests and make plans for the future. The ethos of the leadership of the home had not considered whether the service reflected these values nor were they making plans to do so.
¿ The registered manager told us they were committed to making improvements and to make changes.
Based on our review of safe and well led the service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.
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 good (published in 5 April 2018).
Why we inspected
We undertook this inspection to assess whether the service is applying the principles of Right support right care right culture. This inspection was prompted by a review of the information we held about this service.
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.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to supporting people to be safe, ensuring they have a person-centred care experience and how well led the home is.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.