Villa Maria

Updated 9 February 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 27 January 2021 and was announced.

Updated 9 February 2021

We inspected the service on 13 and 14 June 2018. The inspection was unannounced. Villa Maria is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

Villa Maria is registered to provide accommodation and personal care for 29 older people, people who live with dementia and people with physical or sensory adaptive needs. There were 22 people living in the service at the time of our inspection visit. The service was owned and operated by the Marist Sisters. They are a charitable, religious order. Sixteen of the people living in the service were Marist Sisters with the other residents being ‘lay guests’.

The service was administered on a day to day basis by another charitable, religious body who had been commissioned by the Marist Sisters to run the service. This management charity was responsible for undertaking a range of tasks including the delivery care services and the recruitment, training and deployment of staff. The management charity was also responsible for ensuring compliance with regulatory requirements. The Marist Sisters had formed a Provincial Council formed of three of their number, one of whom was the chair. The council was responsible for managing the service’s finances and for liaising with the management charity.

There was a registered manager in post. 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. In this report when we speak about both the Marist Sisters and the registered manager we refer to them as being, ‘the registered persons’.

At the last comprehensive inspection on 14 February 2017 the overall rating of the service was, ‘Requires Improvement’. We found that there were four breaches of the regulations. The first breach of regulations was because sufficient provision had not been made to provide people with safe care and treatment. This included an instance on which a person was not provided with the right assistance to keep their skin healthy. It also included oversights in the steps taken to monitor some people’s blood pressure and to ensure that other people had enough to drink. The second breach of regulations referred to shortfalls in staffing arrangements because sufficient numbers of suitably qualified care staff had not always been deployed in the service. Another breach of regulations involved oversights in the steps taken to obtain people’s consent to elements of the care that they received. The fourth breach referred to shortfalls in the arrangements used to monitor and improve the service including consulting with people to obtain feedback about suggested improvements.

We told the registered persons to send us an action plan stating what improvements they intended to make and by when to address our concerns and to improve the key questions of 'safe', 'effective' and' well led' back to at least, 'Good'. After the inspection the registered persons told us that they had made the necessary improvements.

At the present inspection we found that sufficient progress had been achieved to meet all of the breaches of regulations. People received safe care and treatment. Enough suitably qualified care staff had been deployed. Suitable arrangements had been made to obtain consent to care and treatment in line with legislation and guidance. The systems and processes used to assess and monitor the operation of the service had been strengthened to ensure that the service could learn, innovate and ensure its sustainability.

Our other findings were as follows. People were safeguarded from situations in which they may be at risk of experiencing abuse. Medicines were managed safely. Background checks had been completed before new care staff were appointed. Suitable provision had been made to prevent and control the risk of infection. Lessons had been learned when things had gone wrong.

Appropriate arrangements were in place to assess people’s needs and choices so that care was provided to achieve effective outcomes. This included providing people with the reassurance they needed if they became distressed. People were helped to have a balanced diet and suitable provision had been made to help people receive coordinated care when they moved between different services. People had been supported to access all of the healthcare services they needed. The accommodation was designed, adapted and decorated to meet people’s needs and preferences.

People were treated with compassion and respect. They were also given emotional support when it was needed. People had been supported to express their views and be actively involved in making decisions about their care as far as possible. This included them having access to lay advocates. They could also obtain support from one of the sisters who was the community leader and who provided pastoral assistance to everyone who lived in the service. Confidential information was kept private.

People received responsive care that met their needs for assistance including care staff supporting them to have access to written information that was relevant to them. Suitable arrangements had been made to promote equality and diversity including provision for the sisters to honour their religious observances. There were suitable arrangements for managing complaints and provision had been made to support people at the end of their life to have a comfortable, dignified and pain-free death.

There was a registered manager who had been supported and encouraged by the Marist Sisters and the management charity to develop an inclusive culture in the service. Suitable arrangements had been made to ensure that regulatory requirements were met. The registered persons were actively working in partnership with other agencies to support the development of joined-up care.