CQC report explained · a residential care home
What the CQC found at Fir Villa Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe medicines management, appropriate risk plans and suitable infection prevention arrangements. The Safe rating improved from Requires Improvement at the last inspection.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found an effective management structure, quality checks and a positive, person-centred culture. People, relatives and staff said the home was well run and concerns were addressed promptly.
What inspectors found, March 2023
Rated Good; inspectors found safe, well-managed care, with one care-record gap to address.
This was an unannounced focused inspection on 22 and 24 November 2022. Two inspectors and an Expert by Experience spoke with one person, five relatives and staff. They also observed the home and checked records and information from other sources.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, well-managed medicines and plans to manage risks such as falls, skin damage and choking. Infection control arrangements were also suitable.
People and relatives said they felt safe, were well cared for and received quick help when needed. The home supported people to make choices and worked with health and social care professionals.
This was a focused inspection, so only Safe and Well-led were reviewed. The other ratings carried over from the previous inspection. Safe improved from Requires Improvement to Good, while the overall rating remained Good.
Medicines managed safely
Inspectors found that medicines were stored correctly and people received them as prescribed. Staff also had detailed, personalised guidance for medicines given when needed.
“Medicines were managed safely. Medicines were stored in line with requirements and people received their medicines as prescribed.” from the report
Enough staff
People, relatives and staff said there were enough staff, including at night. Inspectors also found that recruitment checks helped ensure staff were suitable to work with vulnerable people.
“There were enough staff to keep people safe.” from the report
People felt safe
People and relatives told inspectors they felt safe. Staff knew how to recognise and report possible abuse.
“People and their relatives told us they felt safe.” from the report
Positive management
The home had a person-centred culture and an effective management structure. People and relatives said the manager was approachable and concerns were dealt with promptly.
“There was a positive, person-centred culture at the service.” from the report
Professional advice not in one care file
needs fixingFor one person, advice from a speech and language therapist was recorded in the person's bedroom but not in their care file. The manager said this would be addressed after the inspection.
“For one person, the information from the speech and language therapist was recorded in the person's bedroom but not in their care file.” from the report
- 01How have you made sure the speech and language therapist's advice is now recorded in the relevant person's care file?
- 02How do you check that pressure-relieving mattresses are set correctly for each person's weight?
- 03How do you make sure medicines given when needed are administered using personalised guidance?
- 04How do you check there are enough staff on duty at night as well as during the day?
- 05How are people and relatives involved in decisions about care and feedback about the home?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 17 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2018
Fir Villa Residential Home was rated Good overall, but inspectors rated safety Requires Improvement because medicines management was not robust.
Inspectors visited the home without warning on 8 and 9 October 2018. They spoke with residents, families, staff and health professionals. They also checked care plans, staff files, medicines records, complaints, incidents and quality checks.
Overall, the home was rated Good. Inspectors found kind and respectful care, enough staff, suitable care planning, good support with food and healthcare, activities, and accessible managers.
Safety was rated Requires Improvement. One person missed a medicine for seven days because it was unavailable. Inspectors also found gaps in medicine temperature records and weak oversight when the staff member responsible for medicines was away. The provider responded immediately and said a senior care manager would start in November 2018.
Enough staff
Inspectors found enough staff to meet people's needs. The home had no vacancies and staff covered sickness so care was not compromised.
“There were enough numbers of staff available to keep people safe.” from the report
Kind and respectful care
People and families described staff as caring and supportive. Inspectors saw staff speaking to people kindly and helping them feel at ease.
“Staff treated people with kindness respect and compassion.” from the report
Activities and social life
The home provided regular activities and outings, including celebrations, trips and craft work. Some people and families said this helped residents become more involved.
“The provider was very proud of their activity program and employed an activity co-ordinator who was focused on creating an innovative activity program.” from the report
Visible leadership
The managers were accessible and knew residents' needs. Inspectors found a positive culture and clear lines of responsibility.
“The leadership was visible and accessible.” from the report
Medicine was unavailable
seriousOne person did not receive one of their medicines for seven days because the supply had run out and there was a delay in getting more. This created a safety risk.
“one person had not had one of their medicines administered for seven days because it was unavailable.” from the report
Medicine storage records
seriousThere were gaps in fridge temperature records and no records of room temperatures for backup medicines. This meant staff could not confirm medicines were always stored safely.
“There were gaps in these records for 11 days during September. No record was kept of the room temperatures where back up stocks of medicines were stored.” from the report
Care plan involvement
needs fixingPeople and families were not always given copies of care plans. This made it harder for them to check goals, ask for changes or follow progress.
“staff had not offered them a copy of the care plan which meant people could not review their goals, request changes to be made or monitor their progress when they wanted to.” from the report
Independence outside the home
needs fixingEight people had capacity to go out alone, but staff said people could only leave when supervised. Inspectors asked the manager to review this restriction against current guidance.
“people were only able to go outside the building if they were supervised even though eight people had capacity to go out on their own.” from the report
- 01How do you now make sure medicines are ordered in time and are not missed when the usual medicines lead is away?
- 02Are fridge and room temperature checks for medicines now complete, and who reviews them?
- 03Has the senior care manager started, and what checks are now made on medicines management?
- 04Will residents and families receive copies of care plans and be able to request changes?
- 05How do you assess whether someone can go out independently, and what mental health training has staff completed?
This was an unannounced comprehensive inspection covering all five questions, with inspectors reviewing records and speaking with residents, families, staff and health professionals. This explanation was written from the published report of 16 November 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Fir Villa Residential Home
3 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2018Goodstayed GoodSafe: Requires improvementWell-led: Good
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- October 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 14 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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