North Downs Villa

Updated 23 December 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

This inspection was undertaken by 1 inspector and 1 operations manager.

Service and service type

North Downs 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. North Downs 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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

During the inspection we spoke with 4 people, 3 staff, the registered manager and 2 healthcare professionals. We reviewed 4 people’s care records and 4 staff files which included their recruitment information, training details and supervision records. We checked medicines administration records, the service’s quality assurance processes and a number of policies. We also inspected the property and grounds.

Updated 23 December 2023

About the service

North Downs Villa is a residential care home providing personal care for up to 10 people with mental health needs, some of whom were living with dementia, in one adapted building. At the time of our inspection 5 people were using the service.

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

People were not adequately protected from the risk of abuse. The provider converted part of the care home grounds into a residence for an individual who was neither a resident at the service nor a member of staff. The provider failed to assess the risks to people, visitors and staff in relation to this person. The provider had not followed local authority planning procedures when converting a building in the garden for residential use within the grounds of the care home.

The provider failed to notify the CQC when safeguarding incidents occurred. These included incidents where the local authority safeguarding team substantiated abuse allegations. By failing to notify CQC, in line with the conditions of their registration, the provider prevented us from fulfilling our regulatory function to keep people safe .

Staff did not receive all the training they required to keep people safe. Staff did not receive training in the management of behavioural support needs. This meant the people could not be supported safely and in line with best published practice during challenging situations.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible. The service had a restrictive environment. Doors to the kitchen and laundry rooms were locked and people could not access them without staff being present.

The service was not dementia friendly. The colour scheme and signage did not support the needs of people living with dementia. The provider failed to create a homely setting for people. The lounge did not contain sofas or comfortable armchairs. Instead, there were uncomfortable high back chairs with worn fabric. One had a broken seat. These were arranged side by side around the walls of the lounge and did not make the room welcoming. Walls were marked and needed repainting and the carpet on the stairs had a hole in it. This created a trip hazard.

Quality assurance processes at the service were inadequate. The provider failed to identify and act upon shortfalls. The provider took immediate action in relation to some of the issues we identified at the inspection.

The provider followed appropriate recruitment processes to ensure staff were suitable to provide support to people. People had timely access to health and social care professionals and services when required.

We have made recommendations related to the management of medicines.

Rating at last inspection.

The last rating for this service was requires improvement (published 28 October 2020).

Why we inspected

We received concerns in relation to safeguarding risks and management at the service. As a result, we undertook an urgent comprehensive inspection.

The overall rating for the service has changed from requires improvement to Inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. 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 North Downs Villa on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to people’s protection from abuse, safe care and treatment and the person-centred care people received. We also found breaches related to people’s dignity and respect, staffing, the submission of notifications and the provider’s leadership of the service.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We have requested further action plans 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.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

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