CQC report explained · a nursing home
What the CQC found at The Villa
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Fire safety work was incomplete, some fire doors and emergency lighting had faults, window restrictors were not tamper-proof and the provider had not acted after repeated falls. Staffing, medicines and safeguarding arrangements were positive.
- Effective?
- Good
- Not inspected during this focused visit. The previous rating was carried forward into the overall rating.
- Caring?
- Good
- Not inspected during this focused visit. The previous rating was carried forward into the overall rating.
- Responsive?
- Good
- Not inspected during this focused visit. The previous rating was carried forward into the overall rating.
- Well-led?
- Requires improvement
- The home's audits and incident reviews did not identify important risks or ensure that action was taken. Inspectors also found an open culture where people and staff could give feedback.
What inspectors found, June 2021
Rated Requires Improvement; inspectors found fire safety, window and oversight problems, although staffing and medicines were generally managed well.
This was an unannounced focused inspection on 20 May 2021. Two inspectors spoke with three people, nine staff and reviewed care, medicine, recruitment and management records. They looked only at Safe and Well-led, including infection control.
Inspectors found that fire safety work identified by the home's own risk assessment had not all been completed. Some fire doors had broken closures, some escape routes lacked emergency lighting and window restrictors could be overcome with basic tools. The provider took immediate action about the window restrictors and said it would address other problems.
There was also a failure to act after one person had several similar falls. The home's checks had not identified these problems. Staff numbers, medicines, personalised care plans and safeguarding training were found to be positive areas.
The overall rating fell from Good at the previous inspection, published in February 2019, to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other key questions were not inspected at this visit, so their previous ratings were used in the overall rating.
Enough staff
Inspectors saw enough care staff to meet people's needs, and call bells were answered without people waiting too long.
“On the days of our inspection we observed there were enough care staff to meet people's needs and call bells were answered, so people did not have to wait too long for support.” from the report
Medicines managed well
Qualified nurses administered medicines safely and records showed people received them as directed.
“Systems to manage medicines were organised and ensured safe and timely administration of medicines to people.” from the report
Personalised care plans
Care plans reflected people's needs, wishes and choices. People were also consulted about end of life care.
“People had care plans that were fully personalised to reflect their needs, wishes and choices.” from the report
People could give feedback
People were invited to share their views, and the provider used feedback to make changes such as creating raised vegetable beds.
“People using the service had recently asked about day trips as the pandemic had resulted in one being cancelled.” from the report
Fire safety work incomplete
seriousThe provider had not completed all remedial work identified in its fire risk assessment. Inspectors also found broken fire-door closures and missing emergency lighting on some escape routes.
“The provider had a fire risk assessment carried out 19 August 2020, however, not all the remedial actions identified in the assessment had been carried out.” from the report
Unsafe window restrictors
seriousThe restrictors on all windows were not tamper-proof and could be overcome using basic tools. The provider took immediate action after inspectors raised this.
“During the inspection we saw restrictors fitted to all windows were not appropriate and could be overcome using basic tools.” from the report
Repeated falls not acted on
seriousThe provider had recorded and reviewed accidents but had not reviewed one person's risk assessment or sought professional advice after several similar falls. New equipment was introduced after the inspection.
“The provider had systems in place to review accidents and incidents and investigated to identify ways of preventing them from happening again, this was not robust and had failed to address repeated falls by one person using the service.” from the report
Checks did not find problems
needs fixingThe home's quality audits failed to identify incomplete fire safety work, faulty fire doors, missing emergency lighting and the need to act after repeated falls.
“The service was not maximising opportunities to continuously learn and improve because the current monitoring systems were not identifying areas where improvement was required.” from the report
Infection control shortfalls
needs fixingInspectors saw some open or hand-operated bins, visitors not following the home's visiting policy and some staff not wearing protective equipment correctly. The provider said it took or planned action after these concerns were raised.
“During the inspection we saw some staff failing to wear PPE correctly which could increase the risk of infections being spread.” from the report
- 01Has all the remedial work from the fire risk assessment been completed, including repairs to fire doors and emergency lighting?
- 02What action has been taken to make all window restrictors tamper-proof?
- 03How are repeated falls now reviewed, and how is advice from healthcare professionals obtained when needed?
- 04What changes have been made to quality audits so that fire safety and accident risks are identified promptly?
- 05How are visitors and staff now monitored to ensure the home's infection control and protective equipment rules are followed?
This was a focused inspection of Safe and Well-led, including infection control; the other key question ratings were not inspected and previous ratings were carried forward. This explanation was written from the published report of 29 June 2021 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, February 2019
Rated Good; inspectors found safe, kind and person-centred care, with improvements in mental capacity records.
Inspectors made an unannounced visit on 15 January 2019. They spoke with people living in the home, relatives, staff and a visiting social worker. They observed care and checked care records, staff files, safety records, medicines records and quality checks.
They found that people were safe, treated kindly and supported to make choices. Medicines were managed safely. Care plans and risk assessments were detailed and regularly reviewed. Staff were trained, supervised and recruited with the required checks.
The home had improved its processes for mental capacity and legally authorised restrictions since the previous inspection. Inspectors found that people's consent and choices were being respected. The home was also being refurbished, including changes to furniture and decoration.
The overall rating was Good, and each of the five areas was rated Good. The report says there was no evidence of serious risks or concerns.
Safe medicines
Medicines were managed safely. Staff completed training before administering medicines, and the manager used mistakes as opportunities for retraining and learning.
“Medications were managed safely in the home.” from the report
Respectful care
Inspectors saw staff communicate warmly and respectfully. People were supported to make choices and maintain as much independence as possible.
“We saw staff communicate and engage with care and respect.” from the report
Detailed care planning
Care plans and risk assessments described people's needs and preferences. They were reviewed with people, relatives and other professionals.
“Care plans were reviewed regularly and we asked people and their relatives if they had been involved in setting up and reviewing care plans.” from the report
Improved consent processes
The home had improved its assessments and records about mental capacity. Inspectors found that people's legal right to consent to their care was respected.
“The service had improved processes surrounding mental capacity and the service was now working within the principles of the MCA and DoLS.” from the report
Trained staff
Staff had completed induction, regular training and supervision. Inspectors found evidence that recruitment checks had been completed.
“Staff were recruited safely, received a robust induction and suitable training to do their job role effectively.” from the report
Refurbishment still under way
minorThe home was undergoing extensive refurbishment. Some door guards linked to the fire alarm system were still being replaced when inspectors visited.
“Due to the extensive refurbishment the maintenance person was in the process of replacing door guards, which released the doors when the fire alarm sounds.” from the report
- 01What refurbishment work is still outstanding, and how will it affect my relative's room and daily life?
- 02How do you check that medicines are given correctly, and what happens if there is a medicines error?
- 03How will my relative and our family be involved in creating and reviewing their care plan?
- 04How do you assess whether a person can make decisions about their care, and how are their wishes recorded?
- 05What activities are available, and how will you find out which activities my relative enjoys?
This was an unannounced inspection covering all five areas, with the overall Good rating unchanged; the Effective rating had improved from Requires Improvement at the previous inspection. This explanation was written from the published report of 26 February 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.
Every inspection of The Villa
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- June 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2019Goodstayed GoodSafe: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- February 2015
Registered with the Care Quality Commission on 18 February 2015.
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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