We carried out a review of the data available to us about The Villas Care Homes Ltd on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about The Villas Care Homes Ltd, you can give feedback on this service.
We found the following examples of good practice:
Checks were in place and carried out to reduce the risk of infection from any visitors to the location. We signposted the registered manager to the latest visiting guidance so they could update their visiting policy; they did this and sent us a copy of their updated policy following our inspection.
Measures were in place to reduce and control the spread of infection at the location. For example, from the use of personal protective equipment (PPE) and the availability of hand sanitiser at entrances and throughout the building.
The layout of the premises was used to maximise different spaces for people and safe entry points so as to reduce the risks of any infection transmission.
Information on infection prevention and control and management of risks from COVID-19 were on display to remind staff and visitors of good practice to reduce risks from infection.
Cleaning routines were planned and followed so that the cleanliness of the location was regularly maintained.
Procedures were followed to ensure regular COVID-19 tests were conducted.
Risk assessments were in place to help reduce the risks associated with COVID-19 for people and staff.
The Villas Care Home is a care home providing personal and nursing care for up to 16 people. There were 14 people living at the home at the time of our inspection. The service provides support to people with a learning disability, autistic spectrum disorder and mental health.
The service did not have a manager, the deputy was acting as manager at the time of our inspection.
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 coronavirus and other infection outbreaks effectively.
People’s experience of using this service:
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.
The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. People were given choice and control and supported to live a full life and engage in activities that they enjoyed.
People were kept safe by staff who had received training in how to safeguard people from abuse and the actions they needed to take to protect people from the risk of harm. People were supported by staff who had undergone a robust recruitment process and had the training to enable them to meet people’s needs. Enough staffing numbers were in place to meet the individual needs of people, this enabled people to take part in activities of their choice. People’s medicines were managed safely.
People were treated with dignity and respect and staff engaged well and understood the needs of people who they were supporting. Robust systems were in place to monitor the quality of the service and there was a focus on continuous development to improve quality outcomes for people.
Rating at last inspection:
The last report for The Villas Care Home was published on 26 July 2018 and the service was rated good.
Why we inspected:
The inspection was brought forward due to concerns received about staff not wearing adequate PPE or social distancing. A decision was made for us to inspect and examine those risks. We undertook a focused inspection to review the key questions of safe and well-led only.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Villas Care Homes Ltd on our website at www.cqc.org.uk.
The Villas Care Homes Ltd, accommodates 16 people in one adapted building, which means the service does not conform to Building the Right Support and Registering the Right Support guidance. At the time of our inspection there were 16 people using the service.
The Villas Care Homes Ltd, had a registered manager. 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.
People told us they felt safe. They spoke positively about their involvement in identifying potential risks to their safety and how they worked in partnership with staff to remain safe. Risk assessments were used to develop care plans that identified how staff were to support people in managing risks. People’s rights to make informed decisions and the promotion of people’s independence was central to promoting their safety. People were supported by staff that had been recruited and had checks undertaken to ensure they were suitable for their role. People’s medicine was managed safely and people were aware of the medicines that were prescribed.
People’s needs were assessed to ensure the staff could meet their needs before they moved to the Villas Care Homes. People’s needs were met by staff that had the skills and training to provide good quality care. People’s health care needs were monitored, and people worked in partnership with staff to monitor their health. People were supported to have maximum choice and control of their lives and staff supported them in the least restrict way possible; the policies and systems in the service supported this practice. People were aware of their rights and advocates were actively involved in representing some people in making choices and decisions.
People’s diversity was recognised and celebrated by staff, people expressed themselves in how they dressed and expressed their life, through a range of music styles and community based activities. Staff’s knowledge and awareness of people meant they had developed positive relationships, which included the development of effective communication with those who did not communicate verbally. People spoke positively about the meals, and people’s specific dietary needs were met, including the recognising of diets to meet people’s values and religious beliefs.
People were involved in the development and review of their care plan which ensured people’s needs were met and that staff provided the support and care they required. People made decisions about all key aspects of their lives, which included social and recreational activities. People were supported to be independent in accessing the wider community, which included the organisation of day trips and holidays. People were knowledgeable about making a complaint or expressing a concern and were confident that their concerns would be actioned. Advocacy support was sought to support people in expressing concerns and making complaints. Concerns and complaints were documented and investigated by the registered manager.
The registered person and registered manager provided an open and inclusive environment for both people using the service and staff to share their views and contribute to the day to day running of the service. Staff worked with stakeholders to monitor and develop the service. Opportunities were provided for students from local universities as part of their study to spend time with people using the service, which had a positive impact on people. Systems to review the quality of the service were in place, covered by a range of audits used to review records within the service and the premises.
The Villas Care Homes Limited provides residential and nursing care for up to 16 people with mental health needs or a learning disability. At the time of our inspection there were 15 people using the service. Accommodation is provided over three floors with access via two stairwells or a passenger lift.
The overall rating of Requires Improvement, which was awarded following the CQC's previous comprehensive inspections of 15 and 16 June 2016 and focused inspection of 14 September 2016, was displayed within the service. The Villas Care Homes Limited has made improvements within the individual key questions. Is the service effective? Is the service caring? Is the service well-led? The service has retained its overall rating of Requires Improvement.
The Villas Care Homes Ltd has a registered manager. 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.
The registered manager’s appointment had had a positive impact on the quality of the service being provided. However we found additional improvements were needed to ensure the reviewing of the quality of the service continually ensured that the service being provided was of a good quality, and met the required expectations of the CQC and external stakeholders.
The recruitment of staff was not robust. The provider’s policy and procedure for staff recruitment was not consistently adhered too. Staff recruitment records did not always contain sufficient detail or information to determine the applicants’ suitability for the posts they had applied for. This had the potential to put people at risk. The nominated individual and registered manager accepted that they had not adhered to the policy and procedure and spoke of their commitment to ensure improvements were made.
People’s safety and well-being was promoted through the pro-active management of individual risk. This was achieved through the sharing of information and agreed strategies for promoting people’s choices in their day to day lives. People were supported to have choice and control over their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
People’s medicine was managed safely by nursing staff. Audits were undertaken on a range of topics, which included medicines and maintenance of the environment to ensure people’s safety was promoted and maintained.
We found people’s safety, welfare and needs were met as there were sufficient staff employed who had the relevant experience and training in providing care and support to people. Staff were supervised and had their competence to perform their roles assessed. Communication between the management team and staff was open and enabled the sharing of information.
People contributed to the development of meal choices with staff support. People’s needs with regards to their diet were respected and supported, which included dietary requirements to support individual health needs. People were supported, where necessary, in the promotion of their health and welfare by attending routine and specialist appointments with health care professionals.
People’s individual communication needs were understood by staff, and there was clear guidance for staff on how to support people to express their views about their care and support and make day to day decisions.
The registered manager and staff met the needs of people by encouraging them to share their views and opinions. People were involved in the assessment and reviewing of their care needs, which included the role of staff in promoting people’s independence. People took part in a range of activities at the service and within the wider community, which included visiting local eateries and shops which reflected people’s independent lifestyle choices and diverse needs.
People’s views as to the quality of the service were sought and comments reflected people were satisfied with the care provided. A range of audits were undertaken to assess environmental factors within the service along with audits to ensure people’s needs were being regularly reviewed and being met.
External stakeholders in some instances had noted improvements as to the quality of documentation within the service which recorded people’s needs. The nominated individual and registered manager informed us they were working with a range of external stakeholders to bring about further improvements to the service.
We undertook this focused inspection to check that they had followed their plan and to confirm that they now meet legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Villas Care Homes Ltd on our website at www.cqc.org.uk.
The provider submitted an action plan following the inspection of June 2016 advising us of the action they would take to address the breaches of regulations identified by the 2 September 2016.
The Villas Care Homes Limited provides residential and nursing care for up to 16 people with mental health needs or a learning disability. At the time of our inspection there were 13 people using the service. Accommodation is provided over two floors with access via two stairwells or a passenger lift.
This inspection took place on the 14 September 2016 and was unannounced.
We found improvements had been made.
People’s capacity to make informed decisions about specific aspects of their day to day lives had been undertaken. The capacity assessments had been undertaken by staff who had received the appropriate training. The capacity assessments had been carried out consistent with the Mental Capacity Act 2005 and had included the views of the person being assessed. The assessments to determine people’s capacity had been used to develop plans which provided guidance for staff as to their role in supporting people safely, whilst reflecting the person’s wishes to make decisions about their day to day lives. This meant people’s decisions and choices were being respected.
Risk assessments had been carried out to identify areas of potential risk for those using the service. Where the potential for risk had been found, plans had been put into place, which provided clear guidance for staff as to their role in promoting people’s safety.
Potential risk to people had been identified where they required support with personal care; these risks were managed through the provision of staff training and the use of equipment, and guidance for staff being included within people's records. We found the provider's understanding as to their responsibilities in promoting people's safety did not sufficiently consider and balance their freedom, choice and control. We found instances where decisions had been made, that placed restrictions on people, with no evidence as to how the risk had been determined, or the involvement of the person in the decision.
The manager of the service submitted an application to us to be registered as the manager. Their application was assessed and included an interview. The manager’s application was approved. That meant the service has a registered manager.
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.
The appointment of the registered manager had brought about improvements to the leadership and management of the service. The registered manager has made changes to the day to day management of the service. This has had a positive impact on the lives of people using the service, through the promotion of their safety and through their increased involvement and opportunities created to influence in the care they receive.
Staff received support and guidance from the registered manager, through supervision and meetings. Staff confidence and knowledge has increased through the provision of training, which has increased their confidence and knowledge in the support of people.
Audits have and continue to be carried out. The provider and registered manager were implementing processes to further assess the quality of care being provided and they spoke of their commitment in continuing the development of the service to improve the quality of people’s care.
The rating for the key question ‘safe’ has not been changed following this inspection. This is because the provider needs to demonstrate continued and sustained improvement to practice overtime.
The rating for the key question ‘well-led’ has been changed following this inspection. The provider will need to demonstrate continued development of the service, in order for the rating to be changed in the future.
The overall rating of the service will be re-considered following the next scheduled comprehensive inspection.
The Villas Care Homes Limited provides residential and nursing care for up to 16 people with mental health needs or a learning disability. At the time of our inspection there were 13 people using the service. Accommodation is provided over two floors with access via two stairwells or a passenger lift.
The Villas Care Homes Limited did not have a registered manager in post at the time of our inspection. 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.
The providers understanding and response to promoting people’s safety through the mitigation of risk was not fully understood. Potential risk to people had been identified where they required support with personal care; these risks were managed through the provision of staff training and the use of equipment, and guidance for staff being included within people’s records. We found the provider’s understanding as to their responsibilities in promoting people’s safety did not sufficiently consider and balance their freedom, choice and control. We found instances where decisions had been made, that placed restrictions on people, with no evidence as to how the risk had been determined, or the involvement of the person in the decision.
The environment had undergone some improvement; however we found further improvements were needed to ensure people’s safety and welfare. We found a strong offensive odour in two areas of the service and a kitchenette that had an unpleasant odour and damp. The provider was aware that improvements were needed; however they were unable to provide a timescale as to when the necessary improvements would be made.
We found there were sufficient staff on duty to keep people safe, and people told us they felt safe at The Villas Care Homes and were confident to speak with staff if they had any concerns. Staff had received training which enabled them to promote people’s safety and were knowledgeable as to whom they should report information to should they believe someone was at risk or experiencing abuse.
People’s safety and health were supported by the safe storage and administration of medicine. We found improvements were needed to ensure medicine audits carried out by nursing staff were effective and robust in order that shortfalls were identified and addressed.
People’s understanding of their rights and choice, along with their experiences and views of the service and the provider and staffs ability to provide care and support was mixed. This was influenced by the level of support people required. Where people required support, their lifestyle choices were sometimes restricted as there was not always sufficient staff available to enable them to lead a fulfilling and active life, both within the service and the wider community. Whilst people who were independent were able to access the wider community as they chose.
People were encouraged to have a healthy and balanced diet with a choice of menu being provided. The dining experience was not managed in a way that promoted a pleasant dining experience for people, whilst maximising choice and control. People’s perception and understanding as to their access to food and drink were mixed, this was influenced by people’s level of independence in making their views known and their ability to access drink and food independent of staff.
People had access to a range of health care professionals. Discussions with people showed that some made and attended appointments independent of staff, whilst others required the full assistance of staff. We identified that staff did not always ensure effective monitoring of people’s health as staff did not always recognise changes in people’s behaviour as being potentially indicative that a person’s health needs had changed. Therefore referrals to external health care professionals were not always made.
Staff were responsible for the assessment, development and reviewing of people’s care plans, however, the records we looked at evidenced that staff did not always have the necessary knowledge, skills or training to enable these to be completed effectively. The training available to staff had been limited, with training recently being re-introduced following the appointment of a manager. The manager had recently reintroduced the supervision of all staff and was using this as an opportunity to develop staff skills and knowledge, through constructive guidance and support.
People spoke positively about staff and their role in providing support and care. Staff who had worked at the service for many years had a good understanding of people’s needs and knew their personal preferences, likes and dislikes.
The leadership, management and governance of the service were not robust, which meant the provider did not have a clear direction and plan for the development of the service, based on an assessment of the service that was currently being provided. Therefore the quality of care people received was not fully supportive of individual needs and did not recognise and support people’s choices and freedom and the promotion of their independence.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and The Care Quality Commission (Registration) Regulations 2009.
You can see what action we told the provider to take at the back of the full version of the report.
Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.
This inspection took place on 14 July 2015 and was unannounced.
The Villas Care Homes Limited is registered to provide residential care and support for 16 people with mental health needs and/or a learning disability. At the time of our inspection there were 13 people using the service. The service is a converted residential property which provides accommodation over three floors. The service is located within a residential area and has an accessible garden to the rear of the property.
At the last inspection of the 6 June 2014 we asked the provider to take action. We asked them to make improvements to systems that assess and monitor the quality of the service. We received an action plan from the provider which outlined the action they were going to take and identified their intention to implement changes to be in place by 24 June 2014. We found that the provider had taken the appropriate action and had entered into a contract with an external agency. The provider had undertaken an audit as to environmental improvements, of which some had been acted upon with others having targets dates for achievement over the next eighteen months.
The Villas Care Homes Limited did not have a registered manager in place. A manager had been appointed and had been in post for six weeks at the time of our inspection. The manager advised us of their intention to submit an application to the Care Quality Commission to become registered. We will monitor this situation to ensure that a registered manager is in post to ensure that the service is managed well.
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.
People we spoke with told us they felt safe at The Villas Care Home and were confident to speak with staff if they had any concerns. Staff were knowledgeable as to whom they should report information to should they believe someone was at risk of or experiencing abuse. People’s records included information as to how staff were to keep them safe.
People’s safety was not fully supported as those who were prescribed medicine to take as needed did not have a protocol in place that provided guidance for staff to follow to ensure people received their medication consistently. There was not a robust system for recording the quantity of medicine prescribed for this purpose; therefore it was difficult to determine whether the stock of medicine on site was accurate.
We found there were sufficient staff on duty to meet people’s needs. Staff training systems were not robust as not all staff had received training relevant to their role to meet the needs of people using the service. The provider had recently entered into a contract with an external provider for the purpose of training staff.
Staff until the appointment of the manager had not had been supervised or had their work appraised for some time. This had meant that the service people received had not been monitored for its effectiveness. Staff supervision and meetings had begun to take place and staff spoke positively about the manager stating they were supportive and available.
People were protected under the Mental Capacity Act Deprivation of Liberty Safeguards (MCA DoLS). We found that appropriate referrals had been made to supervisory bodies where people were assessed as not having the capacity to make decisions.
People could speak with the provider, manager or staff if they had any concerns. However they were unclear as to whom they could speak with outside the service, including independent advocates. People were unclear as to their rights. People’s records did not in all instances contain information as to their capacity to make decisions and record their views about aspects of their care. Staff had not undertaken training in the MCA and DoLS.
People’s dietary needs were met and people we spoke with were complimentary about the food. The provider had commissioned a dietician to review the menus and had made suggestions as to how the health of people could be promoted through the implementation of changes to their diet. The provider told us that the service had a smaller kitchen, referred to as the rehabilitation kitchen which was accessible and provided people with an opportunity to make themselves drinks.
People’s health and welfare was promoted as people had timely access to health and social care professionals and were supported by staff to attend appointments.
People spoke positively about the staff. We saw that staff were caring and supportive. Staff provided reassurance when people became distressed and our discussions with staff showed that they were committed to providing a good quality service for people they supported. .
People were involved in the development and reviewing of their plans of care. However their views about their lifestyle choices, for example smoking and the management of their finances were not fully documented to ensure people’s rights and choices were protected. People who smoked were seen smoking outside in a designated area which protected them from the weather.
We noted that people in the afternoon had the opportunity to be entertained by a visiting singer and we saw some people dancing and clapping to the music and singing. We found that people in the morning listened to the television or radio. However, there were few activities taking place in the morning and we did not see any items for people to access to entertain themselves such as games or puzzles.
People told us that they had contact with their relatives, which included going out to local cafes and going on holiday. A number of people were looking forward to a holiday that was being planned by the manager.
The provider had recently appointed a manager. The manager had begun to introduce changes with regards to the day to day running of service in conjunction with the provider. The provider had very recently entered into contracts with external organisations for the provision of staff training along with a quality assurance package that would be used by the provider to audit the quality of the service provided across a range of areas. In addition they would keep the provider abreast of any changes in legislation and provide them with updated policies and procedures. These systems had not as yet been fully implemented and therefore there was limited information for us to view as to their effectiveness.
The manager had, since their appointment, introduced meetings for people using the service as well as staff meetings and staff supervision. This was as a result of feedback from people using the service and staff. Meetings and supervisions were in their infancy and therefore we had limited information to determine whether these had had an impact on people who used the service.
The Villas registered with us in January 2014, not as a new service but under a new provider. This was the new provider’s first inspection.
This inspection was unannounced which meant the provider and the staff did not know we were coming. We spoke with four people living in the home, three staff and the provider. We also spoke with the operations manager and registered manager on the telephone.
Was it safe?
People we spoke with told us they felt safe. One person told us, “I am happy here.” Another person said, “They are good and kind.”
Staff handled medicines safely. Records in relation to medication administration, storage and temperature checks were in place which meant medicines were well managed.
We saw recruitment records demonstrated there were systems in place to ensure the staff were suitable to work with vulnerable people.
The provider and staff understood the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The provider ensured suitable information about capacity and consent was evident. DoLS applications had been made and authorised where appropriate.
Was it effective?
People’s health, care and support needs were assessed with people using the service and/or their relative or advocate. We saw people’s care records were up to date and reflected individual current needs.
People had access to a range of health care professional which included doctors, opticians and dentists to ensure their health needs were met.
People told us they were happy with the care and support they received and their needs had been met. One person said, “I like to do things all the time. They keep me busy and I like doing a lot of art and painting.”
We saw the staff had received training to meet the needs of the people using the service.
Was it caring?
We saw people were supported by kind and attentive staff. We saw staff showed patience and gave encouragement when supporting people. One person told us, “ I like the staff they are caring.”
When speaking with staff it was clear they cared for the people they supported. People told us the staff were kind and thoughtful. The staff knew how to support people in a relaxed and sensitive manner.
People had detailed care and support plans relating to all aspects of their support needs. They contained a good level of information setting out exactly how each person should be supported to ensure their needs were met. People’s preferences, interests, aspirations and diverse needs had been recorded.
Was it responsive?
We saw where people using the service required a GP this had been actioned quickly and the outcomes of the visits were recorded. Information in care plans reflected people’s preferences.
People had access to activities in their own home and also in the community, although there was a clear understanding by the staff that improvements in rehabilitation activities were needed. One person said, “I don’t get bored.” We saw another person had the opportunity to be involved in activities in the home such as laying tables and cleaning the place mats.
Some of the staff were trained in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). We found good information was in place to support people who could not make decisions for themselves.
Was it well led?
The provider needed to improve the environment and their quality assurance systems. We could not see evidence to show that identified problems were addressed promptly.
There were systems in place to make sure the staff learnt from events such as accidents, incidents and concerns. This helped to reduce the risks to people using the service.
Staff told us they were becoming clearer about their roles and responsibilities. Self audits were available and were being implemented by staff.