The Villas Care Homes Ltd

“This focussed assessment was carried out to follow up on the breaches of regulation found at our last assessment. These related to the standards of the premises. We also followed up on information of concern that had been shared with us prior to this assessment relating to the standards of people’s care, safeguarding reporting, the standards of record keeping, management culture and how people were supported to participate in activities. We found the service had made improvements to the premises and are no longer in breach of regulations relating to premises. However, we found 1 breach of the legal regulation in relation to the governance and management of the service.”

“The care home environment was now clean and well-maintained. However, some further actions were needed to ensure people’s home environment remained safe and provided sufficient activities and therapeutic opportunities.”

“There were enough staff available to help people. However not all the required recruitment checks had been completed, and not all staff roles were clearly defined.”

“Care plans and risk assessments were in place. However, these did not always reflect all the actions taken to help people reduce risks.”

“Not all potential safeguarding events had been identified and referred to the local authority safeguarding team when necessary.”

“The provider adhered to the principles of the Mental Capacity Act (2005).”

“People were supported to access a range of health and social care professionals as required, including advocacy services.”

“Medicines were managed in line with good practice guidance.”

“The provider had a shared direction to improve the care home’s environment, and this had been successful. Staff felt confident in the registered manager and felt confident to raise any concerns.”

“However, further improvements were still required to the systems and processes used to ensure the service was well-led. Staff roles were not always clear or recorded accurately and potential impacts on the service were not risk assessed when staff worked long hours over consecutive days. Audits did not always identify reasonable risks in the environment. Incident forms had not always been reviewed to ensure all expected steps had been taken to reduce risks, share with the local authority safeguarding team and notify the Care Quality Commission. Records were not always accurate or complete.”

“We have asked the provider for an action plan in response to the concerns found at this assessment.”