CQC report explained · a nursing home
What the CQC found at Sairam Villa Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm, and staff understood safeguarding, risk management, medicines and infection control. Inspectors noted that some medicines risk assessments were generic and not specific to the person.
- Effective?
- Good
- People's needs were assessed, staff received training and supervision, and people were supported with food, drink and healthcare. Staff understood the Mental Capacity Act and applications had been made where deprivation of liberty safeguards were needed.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff supported people's cultural and communication needs, and involved them in decisions about their care.
- Responsive?
- Good
- Care plans were personalised and regularly updated. People had a range of activities, could make complaints, and had documented end of life care plans.
- Well-led?
- Good
- The provider and management team had systems to monitor quality and meet regulatory duties. People, relatives and staff gave positive feedback about the management team, although there was no registered manager at the time of the inspection.
What inspectors found, June 2019
Sairam Villa Care Home: Rated Good across all five areas; inspectors found kind, personalised care with a small medicines-records weakness.
Inspectors carried out an unannounced visit on 15 May 2019. They spoke with people living at the home, relatives, staff, the manager, the provider and a healthcare professional. They also reviewed care records, medicines records, staff files, complaints, audits and the premises.
The home was rated Good for Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from avoidable harm, received suitable care and support, and were treated with kindness, dignity and respect.
People had personalised care plans, choices about food and activities, and access to healthcare. The home had good systems for checking quality. However, some medicines risk assessments were generic rather than specific to the person, and there was no registered manager at the time of the inspection.
Kind and respectful care
Inspectors observed caring interactions and found that staff respected privacy, dignity and people's choices.
“We observed many kind and caring interactions.” from the report
Personalised care planning
Care plans described people's preferences and emotional needs, and were reviewed when circumstances changed.
“All the care plans we reviewed were clear and comprehensive.” from the report
Communication and culture
Many staff spoke Gujarati, and information was provided in Gujarati and other accessible formats.
“Over 75% of staff supporting people who used the service spoke Guajarati” from the report
Quality monitoring
The management team used audits and monitoring to identify gaps and review the quality of care.
“A system of audits and monitoring helped ensure any gaps in practice or required improvements were identified.” from the report
Some medicines risk assessments were generic
needs fixingInspectors found that a few medicines risk assessments were not specific to the individual. The manager said these would be reviewed and changed.
“However, we noted that these were on a few occasions not specific to the people and were generic.” from the report
No registered manager at the inspection
minorThe home did not have a registered manager when inspectors visited. The manager had applied to the CQC to be registered.
“At the time of our inspection the service did not have a registered manager.” from the report
- 01Have all medicines risk assessments now been reviewed and made specific to each person?
- 02Has the manager's application to register with the CQC been completed?
- 03How are people's cultural, language and religious preferences recorded and followed in daily care?
- 04How are complaints reviewed to make sure lessons are learned and improvements are made?
- 05How are end of life wishes discussed, recorded and reviewed with people and their relatives?
This was a planned, unannounced inspection covering the premises and care provided, with ratings given for all five CQC questions; the previous inspection was rated Good and published in December 2016. This explanation was written from the published report of 8 June 2019 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, December 2016
Sairam Villa Care Home was rated Good; inspectors found safe, kind and responsive care, with some medicine guidance still to be added.
This was an unannounced inspection on 10 November 2016. It was the first inspection since the home registered with the CQC in July 2016. Inspectors spoke with people living there, relatives, staff and a manager. They also checked care plans, risk assessments, medicine records, staff records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicine systems, detailed risk assessments and good access to health professionals. People were treated with kindness and respect, and their choices, cultural needs and activities were taken seriously.
Inspectors praised the design and facilities, including spaces for activities, prayer, relaxation and outdoor use. They found detailed care planning and strong support for people with complex needs. The provider was asked to add clearer guidance for some variable-dose and 'when required' medicines to medicine administration records. Staff training on the Mental Capacity Act and related safeguards was still being arranged for some staff.
Thoughtful environment
Inspectors found the building and facilities had been designed around people's needs. Activities and entertainment could also be streamed into bedrooms for people who were bedbound.
“This demonstrated the service and adaptations were designed around people who used the service and their needs.” from the report
Good safety systems
Staff understood how to recognise and report abuse. Risk assessments were detailed and regularly reviewed, with clear instructions for reducing risks.
“We found that staff had a sound level of understanding of how to keep people safe from harm and this knowledge helped to protect the people using the service.” from the report
Kind and respectful care
People and relatives praised staff's caring attitudes. Inspectors saw staff being friendly, patient and respectful of privacy and dignity.
“We observed staff spoke quietly and treated people with kindness and respect.” from the report
Individual support and activities
Care plans recorded people's choices, likes, dislikes and care needs. The home offered activities such as prayers, films, games, outings and temple visits.
“The care records showed that people had been involved in the planning of their care.” from the report
Supportive management
Staff described the management as supportive and said they worked well as a team. The home used audits, surveys and other checks to monitor its service.
“Staff spoke positively about working at the home They told us they felt valued and that management were very supportive.” from the report
Medicine guidance was not yet on all records
needs fixingSome medicines were prescribed as 'when required' or at a variable dose. Guidance was available in care plans, but inspectors said it would also be helpful to put it beside the medicine administration record for all staff to see.
“We discussed with the manager the possibility of also providing guidance with the person's MAR.” from the report
Some staff training was still being arranged
needs fixingThe manager understood the Mental Capacity Act and related safeguards, but training for the rest of the staff was still being arranged at the time of inspection.
“The manager told us they had received training in the MCA and DoLS and were in the process of arranging training for the rest of the staff.” from the report
- 01Was the extra guidance for 'when required' and variable-dose medicines added to the medicine administration records?
- 02Has all staff training on the Mental Capacity Act and Deprivation of Liberty Safeguards now been completed?
- 03Is there currently a registered manager, given that registration was still in progress at the inspection?
- 04How many people live at the home now, and how are staffing levels adjusted as occupancy increases?
- 05How are residents' and relatives' feedback, surveys and meetings used to make improvements?
This was an unannounced inspection covering all five quality areas; it was the home's first inspection since registering with the CQC. This explanation was written from the published report of 9 December 2016 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 Sairam Villa Care Home
2 rated inspections over 2 years: the service has held its Good rating throughout.
- June 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016
Registered with the Care Quality Commission on 13 July 2016.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Harrow
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,330 a week. 81 can care for a couple. 12 years' experience on average.
“She handled the new situation in front of her with such professionalism and I felt I could trust her 100%.”
“I can truly say that Peter always put Dad at the centre of everything and I know that they found a great friendship in difficult times.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.