North Downs Villa

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed all 7 quality statements from this key question. Based on the findings of this assessment, our rating for this key question has improved to good. Not enough improvement had been made in relation the breach of good governance we found at the last inspection. we found the provider continued to be in breach of this regulation. Staff told us that the registered manager had an open-door policy and was supportive. The registered manager arranged team meetings and invited staff to share their views about improvements to the service. Staff told us they believed significant improvements had been made at the service since our last inspection.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager and staff team had a shared direction for the service.

The culture of the service was discussed this in team meetings and supervision meetings.

Staff told us the registered manager was open and inclusive. They said he was supportive and promoted a healthy work-life balance.

The registered manager was experienced in the role.

Staff felt listened to and supported and felt they had the opportunity to speak up. Staff told us that the registered manager had an open-door policy and was supportive whenever they needed to discuss matters with him.

The registered manager arranged team meetings to discuss people’s care and support and invited staff to share their views about improvements to the service.

The service had a culturally diverse staff team. This meant people had access to support in a number of languages spoken by staff who also held varied religious beliefs. Staff felt the team was treated equally and respectfully by the registered manager.

The provider’s policies supported diversity and anti-discriminatory practice.

The registered manager informed us that they made improvements to the provider’s quality assurance processes and implemented an action plan to address identified shortfalls. Staff told us they believed significant improvements had been made at the service since our last inspection.

At the last inspection we found that the provider failed to assess, monitor and improve the quality of the service and to mitigate the risks to people. This was breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found the provider had improved its quality assurance processes with the assistance of consultants and the local authority. By checking the quality of various aspects of the service, improvements had been made. However, the improved quality assurance processes had not been sufficiently robust so as to identify and address the shortfalls we found with risk assessments, medicines and person-centred planning. This meant the provider continued to be in breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were supported to engage in activities in the community, to meet up with others they wanted to and to receive input from health and social care services.

The provider engaged in collaborative working with the local authority and other providers to support people to resettle.

The provider worked with partners to enable people's transition to new services.

Staff and the registered manager ensured people had the opportunity to engage in activities and sustain relationships. Referrals were made to health and social care professionals when required.

At our last inspection the provider was rated inadequate by CQC and placed into provider concerns by the local authority. The registered manager contracted consultants who advised the service about immediate and essential improvements. The registered manager shared this learning with the staff team.

The provider developed an action plan to meet the breaches identified by CQC at the last inspection and worked with the local authority’s quality team to reduce risks.