Archived: Eastry Villa's

Updated 27 October 2021

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 Care Act 2014.

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.

Inspection team

The inspection was carried out by two inspectors on the first day and one inspector on the second day.

Service and service type

Eastry Villas is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service and received some feedback. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with 10 members of staff including the, operations manager, two consultants, a team leader, support workers and agency staff. We spoke with three people living at the service, some people were not able to verbally communicate so we made observations of staff interacting with people in the communal areas. We reviewed a range of records. This included four people's care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We did not receive all of the information we had requested.

Updated 27 October 2021

Eastry Villa's is a 'care home' for up to 11 people with learning disabilities and mental health conditions. People in care homes receive accommodation and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection, there were eight people living at the service. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

People’s experience of using this service and what we found

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People had been unlawfully restrained by staff and were at risk of harm. There had been numerous incidents which were not reported to the relevant professional stakeholders. Staff did not have the skills or competencies to support people when they were distressed or to support them proactively to manage their behaviours. People’s human rights were not upheld. People were told to ‘be good’ and punished for behaviour staff did not agree with. People had been unnecessarily restricted and were not supported to be independent or make their own choices. The registered manager and provider had poor oversight of incidents and had allowed people to be harmed by staff. The registered manager was involved in incidents of unlawful restraint. The provider had failed to introduce measures to reduce repeated incidents or learn lessons.

Medicines were not managed safely or in line with best practice guidance. There were not sufficient numbers of suitably qualified staff to meet people’s needs. We were not assured that the provider was protecting people from the risk of infection.

There was a closed culture in the service which was not person centred. There was a lack of oversight and leadership at the service. Staff did not understand their responsibilities, as a result people were harmed. The provider did not learn lessons or implement improvements leaving people at risk. Staff, the registered manager and provider were not open, honest or transparent

when things went wrong. The registered manager and nominated individual failed to meet their regulatory requirements. People told us they were not asked for their views or supported to make decisions about the service.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, 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 providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

• The model of care and setting did not maximise people's choice, control and Independence.

Right care:

• Care was not person-centred and did not promote people's dignity, privacy and human Rights.

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services could lead confident, inclusive and empowered lives.

This meant people were placed at harm; had unnecessary restrictions placed on them and did not receive person centred care. The provider had not acted or taken any measures to mitigate the risk of harm to people or support people to live with choice or independence.

Immediately following this inspection, the nominated individual of this service changed.

Following this inspection, we worked closely with local authorities to ensure people were safeguarded from ongoing harm. Eight people were supported to move out of Eastry Villas, there is currently nobody living at Eastry Villas.

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 27 December 2018).

Why we inspected

We received concerns in relation to incidents and allegations of abuse. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Eastry Villas 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 coronavirus and other infection outbreaks effectively.

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, safeguarding, staffing, good governance, and notifications of other incidents at this inspection.

Following the inspection, we took immediate action to restrict admissions to Eastry Villa's. We took action against the provider and cancelled their registration at Eastry Villa's. Everyone moved out of the service and Eastry Villa's is now closed.