The Villa

Updated 29 June 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

This inspection was completed by two inspectors.

Service and service type

The Villa is a ‘nursing home’. People in nursing 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 Villa 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; however, we telephoned the provider from outside the home because of the risks associated with Covid-19. This was because we needed to know of the Covid-19 status in the home and discuss the infection, prevention and control measures in place.

What we did before the inspection

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 reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service about their experience of the care provided and we spent time in the communal area observing the support people received. We spoke with nine staff members including the registered manager, deputy manager, nurse, support workers and domestic staff. We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at four 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. This included seeking evidence regarding the actions they took to remove the immediate risks to people.

Updated 29 June 2021

About the service

The Villa is a nursing home providing personal care to 32 people at the time of the inspection, some of whom were living with dementia. The service can support up to 38 people in an adapted building.

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

People could not be assured the environment would be safe as the provider had not taken necessary action to carry out remedial work as identified in their own fire risk assessment. The undertaking of quality assurance checks did not identify areas where improvements were needed. Window restrictors were not tamper-proof placing people at risk of potential harm.

People could not be assured by the systems in place to assess and manage their safety. Accident and incidents were recorded and reviewed; however, the provider had failed to act after a resident had suffered a number of similar falls.

People's care plans were reflective of their current needs.

People were supported by enough staff who supported them in a timely manner and staff members received training on how to keep people safe from the risk of abuse.

People's medicines were managed effectively.

We found there was a positive culture shared between staff to promote good outcomes for people.

Managers and staff were open and honest. People, their relatives and staff had the opportunity to make changes to the service.

Staff worked in partnership with other healthcare professionals.

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 26 February 2019).

Why we inspected

We undertook this focussed inspection due to concerns shared with us by the fire safety department. They raised concerns about the lack of management of fire systems to ensure the safety of people in an emergency. 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. 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. The overall rating for the service has deteriorated to requires improvement.

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.

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

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 keeping people safe, maintaining a safe environment and the provider’s monitoring of the provision of care at this inspection.

Please see the action we have told the provider to take at the end of this report.

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 request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.