Rose Villa

Updated 29 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of 3 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. A second Expert by Experience contacted relatives of people using the service by phone to obtain their feedback.

Service and service type

Rose Villa is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Rose Villa is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the registered manager, the office manager and the head of care as well as senior care assistants, care assistants and the cook. We spoke with 10 people living at Rose Villa and 1 visiting relative. We also spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We looked at 6 care records, multiple medicines records and documents relating to the management of the service.

Following the inspection, an Expert by Experience spoke with 8 relatives to get their feedback about the service.

Updated 29 March 2023

About the service

Rose Villa is a residential care home providing personal care to up to 20 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 16 people using the service. Accommodation is a mix of single and shared rooms in a converted and extended premises.

People’s experience of using this service and what we found

We had concerns about the providers understanding of the Mental Capacity Act 2005 and records associated with this.

We were not assured that the provider had clear oversight of the service or that CQC had been notified of all significant events in the service including safeguarding concerns. Audits had not identified the shortfalls we found at inspection. Records had not always been accurately completed.

People were cared for by staff trained to identify signs and symptoms of abuse however we were not assured the provider had taken steps to alert the safeguarding authority of all concerns. Some risks to people had not been fully addressed however environmental risks and the premises had been well managed. Staff were safely recruited and there were sufficient staff deployed to meet people’s needs. Medicines were mostly safely managed; however we were concerned that tablets were being counted in a busy area of the service and spoke with the registered manager about this.

The premises were very clean and a programme of further refurbishment would improve this. The premises were being updated to enable easier cleaning of flooring and to redecorate We were assured that current guidance in infection control and visiting care homes was being followed. Some areas of the premises were dimly lit which was not ideal for people living with dementia.

Some assessments needed additional details about how to support people should they be in crisis, but most care plans were informative of people’s needs. Staff received training when they commenced at Rose Villa and updates as needed. There was a focus on supporting staff to achieve qualifications to enable their progression.

A nurse practitioner completed a weekly ward round and addressed any health concerns for people. There were some difficulties in obtaining input from some healthcare professionals.

The service was mostly well-led and the registered manager was working to achieve a more professional approach to service provision. There was a clear management structure and clarity about roles within the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good published 27 January 2020.

Why we inspected

The inspection was prompted in part due to concerns received about medicines, staff conduct, training, awareness of heath conditions and the conduct of the nominated individual. A decision was made for us to inspect and examine those risks. We undertook a focused inspection to review the key questions of safe, effective and well-led only

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Rose Villa on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to notification of significant events in the service, consent, governance and safeguarding. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.