CQC report explained · a residential care home
What the CQC found at Villarose Rest Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, robust recruitment checks, safer medicines systems, updated risk assessments and effective safeguarding arrangements. Infection prevention and control measures were also in place.
- Effective?
- Good
- Staff training and induction had improved. Mental capacity assessments and best-interest decisions were recorded, and people received support with nutrition, healthcare and their assessed needs.
- Caring?
- Good
- This question was not covered by this focused inspection.
- Responsive?
- Good
- This question was not covered by this focused inspection.
- Well-led?
- Good
- The home had introduced audits, meetings and systems for complaints and feedback. The manager was not yet registered with CQC, but an application had been submitted and was being assessed.
What inspectors found, June 2023
Rated Good after improvements; inspectors found safe, effective care and stronger management, but the manager's CQC registration was still pending.
This was an unannounced focused inspection. One inspector visited from 16 to 23 May 2023, spoke with people living in the home, a relative, staff and the manager, and checked care, medicines, recruitment, training, records, the building and infection control.
Inspectors found enough staff, safer medicines systems, updated risk assessments and effective safeguarding arrangements. Staff training had improved, people's consent was being recorded properly, and systems for food, drink and healthcare needs were in place.
Management and record keeping had improved. The home had introduced audits, meetings and a complaints system. The manager had applied to register with CQC, but the application was still being assessed.
The overall rating changed from Requires Improvement to Good. The home was rated Good for Safe, Effective and Well-led. This focused inspection did not assess Caring or Responsive.
Staffing and recruitment
Inspectors found enough staff to meet people's care and social needs. Recruitment checks had become more thorough.
“Sufficient numbers of staff were on duty to support people's care and social needs and promote their independence.” from the report
Safer medicines
Records for receiving, giving and disposing of medicines were in place. Trained staff administered medicines and audits were being used to identify problems.
“Records for the receipt, administration and disposal of medicines were kept.” from the report
Consent and choice
Mental capacity assessments and best-interest decisions were now recorded. Staff had received training and asked for consent before providing support.
“Staff confirmed they asked for people's consent before providing support, explaining the reasons behind this and giving people enough time to think about their decision before taking action.” from the report
Management improvements
The home had introduced audits and a learning programme for staff. Inspectors found these systems supported continuing improvement.
“The manager had introduced a number of auditing systems to maintain ongoing oversight and continued development of Villarose.” from the report
Manager registration pending
minorThere was no registered manager in post at the inspection. A new manager had applied to register with CQC, but the application had not yet been decided.
“At the time of the inspection there was not a registered manager in post.” from the report
Provider information was not submitted
minorThe provider had not completed the required annual Provider Information Return, which CQC normally uses to help plan an inspection.
“The provider did not complete the required Provider Information Return (PIR).” from the report
- 01What is the current position of the manager's application to register with CQC?
- 02What refurbishment work is still planned, and how will it affect residents' rooms and daily routines?
- 03How do you monitor people's food and drink intake and respond if someone is at risk of malnutrition?
- 04What audits are carried out now, and how do you make sure actions from those audits are completed?
- 05How will you keep staff training and induction up to date for new and existing staff?
This was a focused inspection covering Safe, Effective and Well-led, so Caring and Responsive were not assessed in this report. This explanation was written from the published report of 28 June 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, January 2023
Overall Requires Improvement; inspectors found unsafe systems and an Inadequate well-led rating, although people experienced kind care and positive support from the new manager.
Inspectors visited unannounced on 18 November 2022. They spoke with people, relatives, staff and a visiting professional. They observed care, walked around the home and checked care, medicines, staff and management records.
The home was not always safe or effective. Inspectors found gaps in risk assessments, medicine records, staff training and staffing levels. They also found cleanliness and maintenance problems, and records about people's choices, capacity and privacy were not always complete or acted on properly.
The home was rated Requires Improvement overall. Safe and Effective were also Requires Improvement. Well-led was rated Inadequate because checks and records were not reliable enough to find problems and drive improvement. People were generally described as happy and relaxed, and inspectors saw caring interactions.
Kind interactions
People appeared comfortable with staff and spoke positively about the care and manager.
“Observations showed people were happy and relaxed in the company of staff.” from the report
Healthcare support
People were supported to access healthcare, and a visiting professional praised the staff's communication and care.
“People were supported with their healthcare needs.” from the report
Food and nutrition
Inspectors found that meals met people's preferences and nutritional needs. Feedback about the food was positive.
“People were provided with meals that met their preferences and nutritional requirements.” from the report
Manager's response
The new manager responded quickly to problems found during the inspection and began arranging training and new monitoring processes.
“The management team acted swiftly updating documentation, planning training and putting processes in place to manage and lessen the risks identified.” from the report
Risks and emergency equipment
seriousSome personal emergency evacuation plans were wrong or missing. Equipment used to summon help was not always available, and other risks were not properly monitored.
“The provider failed to ensure everyone had a Personal Emergency Evacuation Plan (PEEP) to show staff how to safely support people” from the report
Medicines
seriousMedicine records were incomplete or inaccurate. Some staff lacked the required training, and instructions for additional medicines were not always in place.
“Medicine administration records were not consistently signed.” from the report
Staffing and personal care
seriousThere were not enough staff for all the required tasks. Records showed that most of the people checked had not had the opportunity for a bath or shower for 18 days.
“We looked at 6 people's records and these indicated 5 people had not had the opportunity to have a bath or shower for 18 days.” from the report
Cleanliness and infection control
needs fixingThe home did not look clean and hygienic. Inspectors saw dust, worn furniture, chipped paintwork, poorly handled bedding and unsafe practices with towels and drinking containers.
“The home did not look clean and hygienic. We observed layers of dust in communal areas.” from the report
Management checks
seriousAudits had not been completed consistently for several months. The home's own checks had failed to find problems with medicines, cleanliness, emergency cords, maintenance and privacy.
“Audits had not consistently been completed for some months so the opportunity to identify areas of concern, learn from these and improve standards had been missed.” from the report
Consent and dignity records
seriousMental capacity assessments and best-interest decisions were not always recorded, and required legal applications were missing for some people. One person's privacy was not consistently protected.
“The provider did not always work within the principles of the MCA.” from the report
- 01What has changed to make sure medicines are administered, counted and recorded correctly every time?
- 02How many staff are now on each shift, and how will you make sure people receive regular baths or showers?
- 03Have every person's emergency evacuation plan, emergency pull cord and safety equipment been checked and corrected?
- 04What evidence can you show that audits are now completed regularly and that problems are acted on?
- 05How have you completed the missing Mental Capacity Act assessments, best-interest decisions and legal applications?
This inspection reported current ratings for Safe, Effective and Well-led; Caring and Responsive were not given current ratings in the report, and ratings for key questions not inspected were carried forward from the previous inspection where applicable. This explanation was written from the published report of 19 January 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.
Every inspection of Villarose Rest Home
4 rated inspections over 8 years: the service has held its Good rating throughout.
- June 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2023Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- October 2017Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- September 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 31 May 2011.
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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85 live-in carers within about an hour of Lancashire
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 £1,260 a week. 78 can care for a couple. 11 years' experience on average.
“She understands the needs of an elderly person in the early stages of dementia and has treated my mother with great kindness and skill.”
“Thanks to Tracy, Dad was always immaculately dressed and clean, his meals were all home cooked and nutritionally well balanced and his home was always kept really clean and tidy.”
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.