Archived: Somerset Villa

Updated 20 March 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 16 February 2021 and was announced.

Updated 20 March 2021

.The inspection took place on 3 and 11 January 2018.

Somerset Villa provides accommodation, support and care for up to 16 older people, some of whom are living with dementia. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection 14 people were using the service.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection of this service on 17 May 2017 we rated the service Inadequate and placed it into special measures because we had some serious concern relating to the staffing levels and staff training, recruitment practices, management of risk and of medicines, consent, nutrition, complaints and overall governance of the service. We issued requirement notices for all these breaches of regulation. Since that inspection the service has been acquired by a new owner and a new registered manager has been appointed. The new owner and management team provided us with action plans showing us how they would make the required improvements. They kept us regularly updated on the progress of these action plans. At this inspection we found improvements in all the areas we had previously been concerned about. It was clear to us that a great deal of hard work had been carried out by the new owner of the business and the registered manager. This had brought about some significant improvements at the service and further improvements were planned.

People who used the service and relatives were happy with the care provided and all praised the way the new provider had made positive changes to the safety and quality of the service.

People received safe care. The registered manager assessed and managed risks well. People were supported to be as independent as possible and involved in their local community. Any associated risks were incorporated into their care plan.

Medicines were mostly well managed and people received their prescribed medicines on time. Occasional stocktaking errors meant we could not be fully assured that all medicines were being given as prescribed. The registered manager took prompt action to address the issue and planned to provide staff with further training and support.

Staff understood their responsibilities with regard to keeping people safe from the risk of abuse. Staff were confident and knew how to raise concerns. Individual safeguarding incidents were well managed and the provider was open and transparent when carrying out safeguarding investigations.

Infection control procedures were in place and staff demonstrated a good knowledge of how to reduce the risk and spread of infection.

Staff were trained to carry out their roles and felt supported. A structured system of induction, training, supervision and appraisal had been set up since the last inspection and was welcomed by staff.

People’s needs related to eating and drinking were managed well and records were good. Staff demonstrated a good knowledge of people’s particular needs in this area, although choice could have been improved.

People had good and prompt access to healthcare and staff worked well with other healthcare professionals to meet people’s needs in this area. Healthcare records had been reviewed and were now electronic, which meant information was more easily shared with relevant health professionals.

The service mostly worked in line with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. Some further work was needed to ensure that all decisions taken with regard to the sharing of rooms were done in line with the MCA. Shared rooms did not afford people total privacy and the service needed to confirm that all the people who share rooms were happy with the arrangement.

Staff were kind and caring and demonstrated that they had built up good relationships with the people they were supporting and caring for. People were supported to be as involved in decisions about their care as they wished to be.

People who used the service had the opportunity to follow a variety of hobbies and interests and the provision of activities had greatly increased since our last inspection. Activities were inclusive and many were tailored to those people living with dementia.

New care plans were detailed, person centred and reflected people’s individual needs and preferences. People confirmed that their wishes with regard to their care, were respected.

Care for people at the end of their life was good. There was a commitment to ensuring people had a dignified and pain free death and their wishes relating to the end of their life had been established and recorded.

The service was well-led by the newly appointed registered manager. There was a clear vision for the service and a structured approach to driving improvement. Staff were well supported and there were excellent quality assurance systems in place. We had confidence in the registered manager to continue delivering the good practice we found and to address the concerns which remained. A significant change in the quality of the service had taken place in a short space of time and this is to the new provider’s credit.