CQC report explained · a nursing home
What the CQC found at Village Green Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe, staffing levels had improved and medicines and infection control were managed safely. Some risk assessments needed more detailed guidance, and fire risk assessments were still being reviewed.
- Effective?
- Good
- People's needs were assessed and reviewed, and staff supported nutrition, healthcare and people's choices. Some nursing staff had not completed all the mandatory training expected by the provider.
- Caring?
- Good
- Staff were kind, patient and respectful. People were involved in choices about their care, and staff promoted privacy, dignity and independence.
- Responsive?
- Good
- People had more activities and opportunities to go into the community, and complaints were investigated. Some care plans still needed more personal detail and communication support work was not complete.
- Well-led?
- Requires improvement
- There was a positive culture and the manager had made important improvements. However, audits had not always identified weaknesses, and some systems, plans and staff development arrangements still needed strengthening.
What inspectors found, March 2023
Rated Good overall; inspectors found safe, kind and responsive care, but the home requires improvement in how it is managed and monitored.
Inspectors visited without notice on 8 and 15 March 2023. They spoke with 8 people, 7 relatives and 10 staff. They reviewed care, medicines, staff records and quality checks.
People were found to be safe. There were enough staff, medicines were managed safely, the home was clean and infection controls were effective. Staff were described as kind, respectful and caring.
People's health, food, activities and communication needs were generally supported well. The home had improved since the previous inspection, when its overall rating was Requires Improvement and regulations had been breached.
The overall rating is Good. However, Well-led is Requires Improvement because some care plans, risk assessments, fire safety checks and staff training arrangements were not yet strong or detailed enough.
Enough staff
Staffing levels had been reviewed and increased according to people's needs. People received support promptly and call bells were answered quickly.
“The provider had reviewed and increased staffing levels depending on people's needs to ensure they were supported safely.” from the report
Kind and respectful care
Inspectors saw staff speaking calmly and warmly with people. Staff knew people's preferences and supported privacy, dignity and independence.
“People were treated with kindness and respect by the staff team.” from the report
Improved activities
The home had made clear improvements in helping people follow their interests, take part in activities and go into the local community.
“The manager and staff team had improved the way people were supported to engage in social pastimes and interests.” from the report
Good food and healthcare support
Food looked and smelled appetising, and staff supported people's nutrition and hydration. Staff also worked with health professionals when people's needs changed.
“People were supported to eat and drink in line with their assessed nutrition and hydration needs.” from the report
Care plans and risk guidance
needs fixingSome risk assessments and care plans did not give enough detail to guide staff safely or show fully how to support people as individuals. The manager was updating them.
“Some people's risk assessments and care plans were not detailed enough to fully guide staff how to support people safely.” from the report
Fire safety checks
needs fixingAudits checking fire safety were not always robust. Fire risk assessments for individuals were also being reviewed to reflect current needs.
“Audits to check fire safety were not always robust.” from the report
Staff training and competency checks
needs fixingSome staff wanted training that had not yet been provided. Some nursing staff had not completed expected mandatory training, and further checks of staff competencies were planned.
“Nursing staff had not completed some mandatory training the provider expected them to have completed.” from the report
- 01Which parts of my relative's risk assessment and care plan are being updated, and when will the updates be complete?
- 02How do you check that individual fire risk assessments reflect each person's current needs?
- 03Which mandatory training have nursing staff completed, and what training is still outstanding?
- 04What competency checks do staff complete for person-centred support and day-to-day interactions?
- 05How will you make sure the improvements found at this inspection are maintained over time?
This was an unannounced inspection covering all five key questions, including care, premises, medicines, staffing and management systems. 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, July 2022
Rated Requires Improvement; inspectors found shortfalls in staffing, dignity, activities, medicines records and quality checks.
The inspection was unannounced and took place over visits on 19 May, 24 May and 7 June 2022. Inspectors spoke with people, relatives and staff, and checked care records, medicines records, staff files and management records.
The home was not always safe or reliable. There were times when staffing levels were too low, staff training was incomplete, medicines guidance was unclear and records did not show that care plans were always followed. People also had too little support with activities, community visits and social contact.
Inspectors also found some good practice. People were generally positive about the home, staff kept it clean, supported people to see health professionals and usually respected day-to-day choices. The provider took immediate action during the inspection, but CQC required improvement in all five areas and asked for an action plan.
Clean and infection control
Inspectors were assured that infection prevention arrangements were in place. The home was clean and visitors were supported.
“The service looked and smelled clean.” from the report
Safeguarding awareness
Staff had safeguarding training and understood how to report concerns inside and outside the home.
“Staff were trained in safeguarding and knew who to report any concerns to.” from the report
Health support
Staff helped people access health professionals and followed the advice given.
“Staff supported people to see health professionals such as GP's or physiotherapists if this support was needed.” from the report
Immediate response
The provider acted during the inspection to increase staffing and review rotas so experienced staff were available.
“The provider responded immediately to our concerns. They put more staff in place on the first floor.” from the report
Staffing levels
seriousOn the first visit, staffing was not sufficient to support people safely or provide enough conversation and social contact. This was a breach of Regulation 18.
“there were not enough staff to support people safely.” from the report
Medicines guidance
needs fixingOne person ran out of a prescribed medicine, and instructions for medicines given when needed did not clearly explain when or how to give them.
“People's protocols for 'as and when required medicines did not make it clear when or how these medicines should be administered.” from the report
Respect and dignity
needs fixingSome staff used disrespectful descriptions of people and spoke about them where others could hear. Privacy was not always respected.
“People did not always receive kind and compassionate care.” from the report
Activities and personal choice
seriousPeople were often not supported to follow interests, leave the home or spend time in the community. This was a breach of Regulation 9.
“People were not being supported to follow their social interests.” from the report
Weak quality checks
seriousAudits and care records did not reliably show whether care was being delivered as planned or whether improvement actions had worked. This was a breach of Regulation 17.
“systems were not fully embedded to assess and monitor the quality of the service.” from the report
- 01What staffing levels are now in place on each floor, and how do you make sure experienced staff lead every shift?
- 02Have all staff completed the training the provider says is mandatory, and how are their practical competencies checked?
- 03How do you now record and review medicines given when needed, and how do you prevent prescribed medicines from running out?
- 04What regular activities, outings and community visits are available for my relative, and how are their interests recorded?
- 05How do your audits now check that care plans are followed, records are accurate and improvement actions are completed?
This was an unannounced inspection covering all five CQC key questions, including infection prevention and control under Safe. This explanation was written from the published report of 5 July 2022 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 Village Green Care Home
6 rated inspections over 8 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2022Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- March 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- November 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- December 2016Insufficient evidence to rateSafe: Insufficient evidence to rateEffective: Insufficient evidence to rateCaring: Insufficient evidence to rateResponsive: Insufficient evidence to rateWell-led: Insufficient evidence to rate
- September 2015Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- August 2015Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- December 2014GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2021
Registered with the Care Quality Commission on 18 November 2021.
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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