About the service Villa Maria Private Nursing Home is a residential care home providing personal and nursing care to people aged 65 and over, people with a disability and younger adults. The service can support up to 26 people in one adapted building. There were 22 people living there at the time of the inspection.
People’s experience of using this service and what we found
People were supported to have choice and control of their lives most of the time and staff usually supported them in the least restrictive way possible and in their best interests; the policies and systems in the service were designed to support this practice.
However, during the Covid-19 pandemic and the third national lockdown, there had been occasions when some people had not always been given maximum choice and control over their care and had at times been restricted more than necessary. The provider had stopped visits from people’s families and reduced the amount of time a person could spend out in the community.
Some people were not aware that they could choose when to have their breakfast and other meals and the provider had not always asked people the time they preferred to eat their meals or recorded it in their care plans. This had lead to some people being given their breakfast earlier than they would have liked.
The provider had not always recorded all people's communication needs and preferences in enough detail for staff to know how to communicate with them effectively.
People's lack of choice and control at times meant the provider had not always given all people person-centred care because they had not always responded to people's personal preferences.
There were audit systems and training in place to support continuous learning. However, the provider's auditing systems had not identified the areas of concern we found during our inspection.
People received safe care and treatment and there was a stable staff team with a positive and supportive staff culture.
The provider had robust and effective infection prevention and control policies and procedures in place to protect people from Covid-19 infection.
The provider's policies and practice promoted a positive culture in the home and involved people and their families and staff in the development of the service. People's personal cultural requirements were taken into consideration. People achieved good health outcomes.
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 11 July 2019).
Why we inspected
We undertook this targeted inspection to follow up on specific concerns we had received about the service. The inspection was prompted in part due to concerns received about person-centred care, staff culture and staff turnover, safe care and treatment and infection prevention and control practice. A decision was made for us to inspect and examine those risks.
We inspected and found there was a concern with person-centred care, so we widened the scope of the inspection to become a focused inspection which included the key questions of responsive and well-led.
We looked at infection prevention and control measures under the Safe key question. This was to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
We have found evidence that the provider needs to make improvement. Please see the responsive and well-led sections of this full report.
The overall rating for the service has changed to Requires Improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Villa Maria Private Nursing Home on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to Regulation 9 (Person-centered care) and Regulation 17 (Good governance.)
You can see what action we have asked the provider to take at the end of this full report.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.