North Downs Villa

North Downs Villa is a residential care home providing personal care for up to 10 people with mental health needs, some of whom were living with dementia, in one adapted building. At the time of our inspection 5 people were using the service.

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

People were not adequately protected from the risk of abuse. The provider converted part of the care home grounds into a residence for an individual who was neither a resident at the service nor a member of staff. The provider failed to assess the risks to people, visitors and staff in relation to this person. The provider had not followed local authority planning procedures when converting a building in the garden for residential use within the grounds of the care home.

The provider failed to notify the CQC when safeguarding incidents occurred. These included incidents where the local authority safeguarding team substantiated abuse allegations. By failing to notify CQC, in line with the conditions of their registration, the provider prevented us from fulfilling our regulatory function to keep people safe .

Staff did not receive all the training they required to keep people safe. Staff did not receive training in the management of behavioural support needs. This meant the people could not be supported safely and in line with best published practice during challenging situations.

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. The service had a restrictive environment. Doors to the kitchen and laundry rooms were locked and people could not access them without staff being present.

The service was not dementia friendly. The colour scheme and signage did not support the needs of people living with dementia. The provider failed to create a homely setting for people. The lounge did not contain sofas or comfortable armchairs. Instead, there were uncomfortable high back chairs with worn fabric. One had a broken seat. These were arranged side by side around the walls of the lounge and did not make the room welcoming. Walls were marked and needed repainting and the carpet on the stairs had a hole in it. This created a trip hazard.

Quality assurance processes at the service were inadequate. The provider failed to identify and act upon shortfalls. The provider took immediate action in relation to some of the issues we identified at the inspection.

The provider followed appropriate recruitment processes to ensure staff were suitable to provide support to people. People had timely access to health and social care professionals and services when required.

We have made recommendations related to the management of medicines.

Rating at last inspection.

The last rating for this service was requires improvement (published 28 October 2020).

Why we inspected

We received concerns in relation to safeguarding risks and management at the service. As a result, we undertook an urgent comprehensive inspection.

The overall rating for the service has changed from requires improvement to Inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. 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 North Downs Villa on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to people’s protection from abuse, safe care and treatment and the person-centred care people received. We also found breaches related to people’s dignity and respect, staffing, the submission of notifications and the provider’s leadership of the service.

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 have requested further action plans 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for North Downs Villa on our website at www.cqc.org.uk.

North Downs Villa is a residential care home providing personal care for up to eight people with mental health support. At the time of our inspection seven people were using the service.

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

Improvements had been made in the way people’s medicines were managed. Systems for medicine storage had improved and audits made sure people had been given the right amount of medicine when they needed it.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. Where people were restricted from certain areas of the home the registered manager had considered people’s risk and ways to encourage people’s independence safely.

The provider had made some improvements with the assessments of people’s mental health needs. They had recorded information for staff to help them understand when people may need additional support with their mental health. People’s care records had improved offering staff more information about people’s likes, dislikes, interests and hobbies.

Governance systems had improved and the provider was giving more support to the registered manager. This meant the registered manager had more time to make improvements to the service. For example, care records were regularly reviewed, new audits had been introduced to make sure people received safe care and maintenance issues were dealt with in a timely way. We want to make sure the improvements made continue and the provider looks for new ways to improve the quality of care for people following best practice. We will continue to monitor the providers progress in this area.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was Requires Improvement (published 25 October 2019) and there were four breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations. However, the service remains rated as requires improvement because it was too early to judge whether improvements could be maintained continuously over a sustained time period. We need to make sure the improvements made are consistent and embedded into the culture of the service.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. Our focused inspection covered our findings in relation to the Key Questions Effective and Well-led. We also looked at Safe and Responsive as part of a targeted inspection to check whether the breaches in these areas had been met. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for North Downs Villa on our website at www.cqc.org.uk.

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.

North Downs Villa is a residential care home providing personal care to 7 people with mental health support needs at the time of the inspection. The service can accommodate up to 10 people with mental health needs and/or learning disabilities in one adapted building. This includes the provision of respite care.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. There were no people with learning disabilities using this service at the time of the inspection, although people with learning disabilities have used the service in the past. Because of this, we have not reported on whether the service was providing care and support in line with current best practice guidance for learning disability services.

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

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests. Although the policies and systems in the service supported this practice in terms of helping people to make decisions about their care, there were some restrictive practices around access to facilities at the home.

Medicines were not always managed safely so people had a risk of not receiving their medicines as prescribed. Medicines were not always stored safely and there was no system to ensure the correct amount of some tablets was in stock. Administration of topical medicines was not always recorded. However, other medicines were recorded appropriately.

The provider did not assess people’s mental health needs, measure their mental health outcomes or plan their care in line with evidence-based guidance. Staff did not have all the information they required to make sure they met people’s mental health needs. There was also a lack of personalised information about people that would help the provider plan person-centred care.

There were some inconsistencies in the quality of leadership, because the registered manager did not always receive the support they needed. There were no senior staff, which meant care staff lacked opportunities for promotion and development.

Governance systems were not always effective because the registered manager did not delegate many tasks to staff and had taken on too much work, meaning important tasks were sometimes missed. Because some care records were out of date or unclear, people may have been at risk of receiving care that was not appropriate to their needs. The provider did not always make improvements within an appropriate timescale when the need was identified.

Staff received training and sufficient support from the provider. However, they did not receive training in specific mental health conditions, which may have helped them understand people’s mental health needs better.

There were systems to protect people from abuse and ill-treatment. Risks to people’s safety were managed appropriately, including the risk of infection spreading. There were enough staff to care for people safely and the provider carried out checks to make sure staff were suitable to work with people. There were processes for the provider to learn from accidents and incidents.

People had enough to eat and drink, received support to eat when needed, and were able to choose from a variety of menu options. Staff gave people appropriate advice on staying healthy, including healthy eating, and provided support for people to access healthcare services. People were also able to access regular art therapy sessions, which was a useful tool for people to understand and manage difficult emotions.

People received care and support from caring, respectful and compassionate staff who took time to get to know them and help them feel comfortable. People had opportunities to express their views about their care. Staff made sure people understood what their care options were and supported them to be involved as partners in planning their care. Staff understood how to support people in ways that promoted their privacy, dignity and independence.

People knew how to complain and said they would be comfortable doing so, but the complaints policy needed more detail to give people the information they needed about the process. Staff supported people to set and work towards meaningful short and medium term goals. They provided people with support to access their local community, plan activities and maintain important relationships. People received the information they needed in an appropriate format. One person told us, “I’m happy here – I love it here.”

The provider used meetings and surveys to gather the views of people and staff, who told us they were able to raise any issues they wanted to. Staff and the registered manager shared information effectively as a team and with other organisations when needed.

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 requires improvement (published 4 February 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches of regulations in relation to safe care and treatment and dignity and respect. Please see the action we have told the provider to take at the end of this report.

We have also identified breaches of regulations in relation to good governance and person centred care. 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 for 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.

North Downs Villa 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. North Downs Villa does not provide nursing care.

North Down Villa accommodates up to eight people in one adapted building, and a further two people in a separate bungalow on the same grounds. At the time of our inspection eight people were using the service and the bungalow was no longer in use. North Downs Villa provides a service for people with learning disabilities and/or a mental health diagnosis.

We carried out an unannounced comprehensive inspection of this service on 6 July 2018. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to staffing and good governance.

We undertook this focused inspection to check that the provider had followed their plan in relation to the key questions ‘Is the service Effective and Well led?’ and to confirm that they now met legal requirements in relation to the warning notice we served. This report only covers our findings in relation to those requirements and we will inspect in relation to the other issues we identified previously at our next comprehensive inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for North Downs Villa on our website at www.cqc.org.uk.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found the provider had met the requirements of the warning notice. The provider had improved the arrangements for staff training and supervision to ensure that people received appropriate care and support. Further improvements were planned which we will check at our next inspection.

The provider had systems for monitoring the quality and safety of the service although these needed to be embedded and sustained in practice, to ensure the provider had effective oversight.

Whilst the provider had taken sufficient action to meet the legal requirements that were being breached at the last inspection, we have not improved our rating for the service. We need to see consistent improvements over time before we are able to change the rating of this service from ‘requires improvement’.

North Down Villa accommodated up to eight people in one adapted building, and a further two people in a separate bungalow on the same grounds. At the time of our inspection nine people were using the service. North Downs Villa provides a service for people with learning disabilities and/or a mental health diagnosis.

At our previous inspection on 19 February 2018 we rated the service ‘requires improvement’ and found the provide in breach of four regulations of the HSCA 2008. This included in relation to staffing, premises, need for consent and good governance.

We undertook an unannounced comprehensive inspection on 6 July 2018. This inspection was done to check that improvements to meet legal requirements planned by the provider after our February 2018 inspection had been made. The team inspected the service against all of the five questions we ask about services. This is because the service was not meeting some legal requirements in four of the questions so we wanted to review the quality and safety of all areas of service delivery.

A registered manager remained in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found some improvements had been made, however, there continued to be some concerns and the service continued to be rated ‘requires improvement’ overall. We found the service continued to be in breach of regulations relating to staffing and good governance. You can see what action we have asked the provider to take at the back of the main report.

Staff continued to not receive adequate training opportunities meaning there was a risk that staff would not have the knowledge and skills to meet people’s needs and support them safely. We also found that staff continued to not receive supervision meaning there was a risk that staff were not adequately supported to undertake their duties.

Governance processes had been strengthened and regular cleanliness and environmental checks had been introduced. However, we found that quality assurance processes still needed improving to ensure they reviewed all areas of service delivery and ensure they were effective in implementing improvements in a timely manner.

Improvements had been made since our previous inspection to ensure a safe, pleasant and fit for purpose environment was provided. The bathrooms had been renovated and new window restrictors had been installed. We also saw improvements had been made to ensure people were only deprived of their liberty when staff were legally authorised to do so. The registered manager had applied to the local authority for authorisation to deprive people of their liberty where they did not have capacity to ensure their safety in the community.

Improvements had also been made to ensure there were sufficient staff to meet people’s needs. New staff had been recruited which meant there were now sufficient numbers of staff on each shift to meet people’s needs and to allow staff to have sufficient breaks between shifts. However, we saw recruitment practices needing improving to ensure sufficient references were obtained from previous employers.

People’s care records had been reviewed and updated. Improvements had been made to ensure these records incorporated advice from health and social care professionals and that care records were developed in a timely manner so staff had information about people’s historic and current risk behaviour and support needs.

Staff supported people to identify and manage risks to their safety. They liaised with health and social care professionals as required in order to have people’s health and care needs met. This included liaising with representatives from people’s community mental health teams and attending psychiatric reviews. People were empowered to be involved in care decisions and attend care reviews. Staff were aware of who had capacity to make decisions about their care, and who had been appointed to make decisions on their behalf if they did not have the capacity to make certain decisions. People received their medicines as prescribed and safe medicines management processes were in place.

Staff had built friendly, caring relationships with people. We observed people and staff interacting in a kind and compassionate manner. Staff were respectful of people’s privacy and maintaining their dignity. Staff were aware of who was important to people and people’s friends and family were welcome to visit the service.

Staff were aware of safeguarding adults’ procedures. There had been no safeguarding concerns raised since our previous inspection. The complaints process remained in place. No complaints had been made since our previous inspection. Staff adhered to infection control procedures and processes had been improved to monitor the cleanliness of the service.

At our last inspection on 5 January 2016 we rated the service ‘good’ overall and for each key question. At this inspection we found the quality of the service had deteriorated and the service was now rated ‘requires improvement’ overall and in four key questions.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were insufficient staff employed to meet people’s needs. The management team told us they had struggled to recruit staff and there were currently a number of vacancies in the staff team. This meant that staff were being required to work very long hours and not have adequate breaks between shifts. The pressures on staff’s time also meant new staff were not being adequately supported and given the time to complete the provider’s mandatory training in a timely manner impacting on their knowledge of key processes. Staff were also not receiving regular supervision.

The premises were not adequately maintained in order to provide a safe and pleasant environment for people to use. Two of the bathrooms needed refurbishment. Water damage had affected the flooring in one bathroom which was posing a trip hazard and impacted on the ability to maintain a clean environment. The window restrictors in place could be overridden meaning people were not adequately protected from the risk of falling from height.

There were insufficient systems in place to monitor and improve the quality of service delivery. The management team did not have systems in place to review the cleanliness of the service and ensure infection control procedures were adhered to. There was no formal tool in place to review the health and safety of the environment. Systems were not in place to review arrangements regarding management of people’s finances. Complete and contemporaneous care records were not always maintained in a timely manner and care records were not always updated to reflect changes in people’s needs and incorporate advice from specialist healthcare professionals.

Staff did not consistently adhere to the Mental Capacity Act 2005 and had not consistently applied for legal authorisation to deprive a person of their liberty. Whilst the registered manager had followed process to ensure staff were legally authorised to deprive two people of their liberty, we saw for a further two people using the service the registered manager had not followed process in regards to the deprivation of liberty safeguards (DoLS).

Staff adhered to safeguarding adults’ procedures. Staff liaised with people’s mental health care team to identify and manage risks to people’s safety. Incidents were reviewed and learnt from to improve the quality of risk management. People received their medicines as prescribed. Staff supported people with their nutritional needs and liaised with healthcare specialists in order to support people to have their physical and mental health needs met.

Staff had built friendly and caring relationships with people. Staff were aware of people’s communication needs and communicated with people in a way they understood. Staff respected people’s privacy and their individual differences. People were supported to maintain relationships with friends and family, and visitors were welcomed at the service. Staff provided any support required in regards to cultural and religious preferences.

Staff were knowledgeable about people’s needs and encouraged them to develop their daily living skills. Staff supported people to access the local community and people enjoyed day trips out organised by the staff. A complaints process remained in place, although no complaints had been received since last inspection.

The registered manager adhered to the requirements of their CQC registration. There were systems in place to obtain people’s and staff’s feedback about the service. Staff felt they were able to have open and honest conversations with the management team and staff were clear about their roles.

The provider was in breach of legal requirements relating to premises, staffing, good governance and need for consent. You can see what action we have asked the provider to take at the back of this report.

During this inspection we met with two of the people using the service, two support workers and the manager.

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service Safe ?

At the inspection on 29th May 2014 we found the quality assurance checks were inconsistently carried out, and nobody was checking when the audits took place or if the areas needing attention were addressed. This was a follow up inspection to check that the compliance actions had been met. At this inspection we found that the new manager had introduced more robust methods that promoted the safety and welfare of people using the service and of staff. An external consultant had completed a fire risk assessment, and this identified a number of areas requiring attention in the premises. To address the issues the manager arranged with the contractor to undertake the remedial work. This took place and included new emergency lighting, fire exit changes and new signage.

Is the service well led?

We saw that the newly appointed manager had provider direction and clear leadership to the staff team. They helped make the necessary improvements to quality assurance processes. They introduced regular formal supervision to help ensure staff were effectively supported. The manager established forums for staff through regular team meetings, and people using the service had regular care reviews. The manager has contributed to improvements in communication with external health professionals which was of benefit to people using the service.

Below is a summary of what we found.

The summary is based on our observations during the inspection, speaking with four of the five people using the service, speaking with the staff and from looking at records. We requested information from the provider and spoke with three community based mental health care professionals who visited the service on a regular basis.

Is the service safe?

People were protected from the risk of abuse. Staff were knowledgeable in recognising signs of abuse and were aware of the reporting procedures to the local safeguarding team. Risks to individuals and to others using the service were identified and managed appropriately.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Relevant staff had been trained to understand when an application should be made, and in how to submit one. This meant that people were safeguarded as required.

People were not totally safe because of risks associated with the premises that needed to be addressed. There was a schedule of work required to address these concerns following a recent fire risk assessment. The manager confirmed the planned schedule of work was to commence 12th June. We shall return to the service at a later date to check if the work is completed.

Is the service effective ?

Individual support/care plans were in place detailing the care and support needs of people who used the service. People used all the information to deliver the care and support people needed. People benefited from having support from staff that were knowledgeable and competent.

A care co-ordinator from the local NHS mental health trust told us they found people received the care and support they required. They said staff were proactive and kept them up to date on a person's progress, and worked closely with them so that they were made aware if there any setbacks or concerns.

Is the service caring ?

People who used the service told us they enjoyed life in this home. One person told us, 'this is my home, the happiest place I have been, people looking after me are caring, and understand how to make me smile if my mood is down." People liked the staff team and felt they gave them the support and encouragement they needed.

People were involved in decisions about their care. We saw that, when they wished, people signed their support plans to indicate they were in agreement with the plans in place.

Is the service responsive to people's needs?

People found staff were responsive, for example a person said "I needed help with my diabetic diet, and staff have helped me". Two care coordinators from a mental health team told us staff were responsive to people's needs. They found staff were innovative and focused on delivering the support that met individual interests and preferences. The service empowered people and enabled them participate in the local community.

Is the service well-led?

The service was without a manager for a substantial period before April 2014, this directly impacted on the service and the processes in place to monitor and evaluate the quality of the service. Any areas for improvement were not identified and addressed.

Since the appointment of a new experienced manager we found improvements to the quality assurance audits and processes were in progress. There were regular staff meetings to discuss any changes to service provision and to give information to the team about changes in practice.

Meetings had also begun with people using the service. The manager had developed quality surveys and was seeking the view of people using the service, and those of staff and stakeholders.

We spoke with two members of staff and the registered provider who was also managing the home. Following our inspection we also spoke with two social care professionals involved with the service.

We met with three of the four people using the service. They were happy with the support they received. Their comments included, 'I like it here' and 'the staff are ok, they take me bowling.' A social care professional said that the provider 'worked well with the team (mental health services) and passed on information appropriately.'

People told us that staff listened to them and that they felt safe. People said they could talk to staff if they had any worries or concerns. They met regularly with other health and social care professionals to ensure that they stayed as well as possible.

People using the service had personalised care plans, which were current and outlined their agreed care and support arrangements. This meant staff had the information they needed to meet people's individual needs.

At this inspection we found there had been improvements. There were sufficient numbers of staff to meet people's needs and the provider had taken some action to improve upon staff training and supervision. The service's recruitment process and quality monitoring systems had been strengthened. We were told that a new manager had been appointed and they were applying for registration with us.

People spoke positively about the support they received and their experiences of the home. Comments included, 'I like it here and the staff are friendly' and 'the staff are caring and listen.'

We received positive comments about the meals provided and the home environment. They included, 'the food is nice, I get a choice' and 'all meals are home cooked.' People said they chose their rooms and had furnished them as they liked.

People confirmed they felt safe living in the home and that staff listened to them and were approachable. One person commented, 'they are always available to talk to.'

People told us they received ongoing advice and treatment from health and social care professionals to ensure that they stayed as well as possible.

We found however that staffing levels were insufficient to meet the needs of the people using the service. There were also inadequate arrangements to ensure that staff were appropriately recruited, trained and supervised. The registered provider was not fully aware of the government standards of quality and safety which may adversely affect the quality of care that people receive. The home also needs a registered manager who is qualified, competent and experienced.