CQC report explained · a nursing home
What the CQC found at Villa Maria Private Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Responsive?
- Good
- People had choice over their routines, meals, visitors and activities. Their care records included their histories, likes, dislikes and personal outcomes.
- Well-led?
- Good
- New management and auditing arrangements had been introduced. Audits covered areas including the environment, care records, medicines and staff files.
What inspectors found, March 2023
Rated Good; inspectors found improved choice, activities and management, but this inspection did not check all five care areas.
This was an unannounced focused inspection on 24 February 2023. Inspectors spoke with people, staff and managers, reviewed four care records, complaints, audits and infection control records, and made general observations.
The home was rated Good for Responsive and Well-led. People had more choice about daily routines, meals, visitors and activities. Care records were personalised, and people could keep in touch with relatives and take part in community activities.
Management had improved since the previous inspection. New auditing arrangements and electronic care records helped the home identify and respond to shortfalls. The previous overall rating was Requires Improvement, but the home was no longer in breach of regulations.
This was a focused inspection. The ratings for Safe, Effective and Caring were not inspected during this visit and were carried forward from the previous inspection.
Choice and personalised care
People could choose when to get up and go to bed, where to eat, what activities to do and when to receive visitors. Their care records reflected their preferences and personal outcomes.
“People chose how they received their care and support.” from the report
Activities and relationships
Staff helped people keep in touch with relatives and take part in activities inside the home and in the community. People spending most of their time in bedrooms were offered individual activities.
“Staff supported people to engage in activities in the community.” from the report
Improved management
A new registered manager and operations manager had introduced stronger checks. Electronic care records helped managers monitor changes in people's needs and risks.
“They introduced new auditing processes to drive improvements.” from the report
Listening and learning
The provider gathered feedback and reviewed incidents such as falls, complaints and safeguarding concerns. Lessons were shared with staff to reduce the risk of problems happening again.
“At these meetings issues such as falls, complaints and safeguarding were reviewed, and the lessons learned were shared with staff.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current ratings and findings for Safe, Effective and Caring, which were not checked during this inspection?
- 02How do you check that medicines, care records, the environment and staff files remain accurate and up to date?
- 03What changes have been made since the new registered manager and operations manager took up their roles?
- 04How will you make sure my relative can choose their daily routine, meals, visitors and activities?
- 05How do you use feedback, complaints and incidents to make changes to people's care?
This was an unannounced focused inspection of Responsive and Well-led; Safe, Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 24 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, May 2021
Villa Maria Private Nursing Home was rated Requires Improvement; inspectors found safe infection control but gaps in choice, communication records and quality checks.
This was an unannounced inspection on 23 February 2021. One inspector spoke with people, a relative, staff and a visiting professional. Records and the provider's quality checks were also reviewed.
The inspection focused on concerns about person-centred care, staff culture, staff turnover, safe care and infection control. Visits from families had been stopped during lockdown without individual risk assessments. Some people were not given enough choice about meal times, outings or other parts of their care. Communication needs were also not recorded clearly enough.
The home was found to have safe care and strong Covid-19 infection control in most areas. However, its checks had not found the problems inspectors identified. The overall rating fell from Good at the previous inspection, published on 11 July 2019, to Requires Improvement.
Infection control
The home had effective Covid-19 infection control arrangements in most areas. Inspectors were assured about PPE, testing, hygiene and managing outbreaks.
“The provider had robust and effective infection prevention and control policies and procedures in place to protect people from Covid-19 infection.” from the report
Safe care and teamwork
People received safe care and treatment. Inspectors found a stable staff team, good teamwork and supportive working relationships.
“People received safe care and treatment and there was a stable staff team with a positive and supportive staff culture.” from the report
Activities and relationships
People could choose from varied activities, including individual activities based on their interests. The home helped people keep in touch with families during lockdown.
“An activities coordinator provided a varied range of activities to keep people entertained and stimulated.” from the report
Complaints
People and relatives knew how to complain. Records showed that complaints were investigated, answered and monitored for possible improvements.
“Records showed how the service had responded to complaints along with a report of the outcome and any action taken in response.” from the report
Limited choice
seriousSome people were not told they could choose when to eat breakfast, and preferred meal times were not always recorded. Visits and community outings were also restricted without individual risk assessments.
“The provider had not always given all people choice and control over all aspects of their care.” from the report
Communication records
seriousSome care plans did not explain people's communication needs or how staff should communicate with them. This meant staff might not know how to communicate in the person's preferred way.
“People's communication needs were not always recorded in enough detail for staff to communicate effectively with the person and in their preferred way.” from the report
Quality checks missed problems
seriousThe home's audits did not identify the shortfalls found by inspectors, including problems with choice, communication records, visits and a resuscitation decision.
“The provider's failure to have effective systems to assess, monitor and improve the quality of the service was a breach of Regulation 17” from the report
Resuscitation decision
seriousOne person's do-not-attempt-resuscitation decision had not been reviewed when their circumstances changed, and it did not reflect what the person told inspectors. The record was corrected during the inspection.
“However, this had not been reviewed and the person told us they did want to be resuscitated.” from the report
- 01How do you now record and check each person's preferred breakfast and meal times?
- 02How are people's communication needs recorded, and how do staff learn the best way to communicate with each person?
- 03How do you individually risk assess family visits and community outings rather than applying blanket restrictions?
- 04How are resuscitation decisions reviewed when a person's wishes or circumstances change?
- 05What new checks make sure the problems identified in this report are found and corrected promptly?
This was a targeted inspection that widened to focus on Responsive and Well-led, with infection control looked at under Safe; Effective and Caring were not inspected and their previous ratings carried over. This explanation was written from the published report of 6 May 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.
Every inspection of Villa Maria Private Nursing Home
5 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Villa Maria Private Nursing Home →
- May 2021Requires improvementdown from GoodSafe: Inspected but not ratedResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Villa Maria Private Nursing Home →
- July 2019Goodup from Requires improvementResponsive: GoodWell-led: Good
- June 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Registered with the Care Quality Commission on 13 May 2014.
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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