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Inspection Summary

Overall summary & rating


Updated 26 May 2018

.The inspection took place on 3 and 11 January 2018.

Somerset Villa provides accommodation, support and care for up to 16 older people, some of whom are living with dementia. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection 14 people were using the service.

There was a registered manager in place. 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.

At our last inspection of this service on 17 May 2017 we rated the service Inadequate and placed it into special measures because we had some serious concern relating to the staffing levels and staff training, recruitment practices, management of risk and of medicines, consent, nutrition, complaints and overall governance of the service. We issued requirement notices for all these breaches of regulation. Since that inspection the service has been acquired by a new owner and a new registered manager has been appointed. The new owner and management team provided us with action plans showing us how they would make the required improvements. They kept us regularly updated on the progress of these action plans. At this inspection we found improvements in all the areas we had previously been concerned about. It was clear to us that a great deal of hard work had been carried out by the new owner of the business and the registered manager. This had brought about some significant improvements at the service and further improvements were planned.

People who used the service and relatives were happy with the care provided and all praised the way the new provider had made positive changes to the safety and quality of the service.

People received safe care. The registered manager assessed and managed risks well. People were supported to be as independent as possible and involved in their local community. Any associated risks were incorporated into their care plan.

Medicines were mostly well managed and people received their prescribed medicines on time. Occasional stocktaking errors meant we could not be fully assured that all medicines were being given as prescribed. The registered manager took prompt action to address the issue and planned to provide staff with further training and support.

Staff understood their responsibilities with regard to keeping people safe from the risk of abuse. Staff were confident and knew how to raise concerns. Individual safeguarding incidents were well managed and the provider was open and transparent when carrying out safeguarding investigations.

Infection control procedures were in place and staff demonstrated a good knowledge of how to reduce the risk and spread of infection.

Staff were trained to carry out their roles and felt supported. A structured system of induction, training, supervision and appraisal had been set up since the last inspection and was welcomed by staff.

People’s needs related to eating and drinking were managed well and records were good. Staff demonstrated a good knowledge of people’s particular needs in this area, although choice could have been improved.

People had good and prompt access to healthcare and staff worked well with other healthcare professionals to meet people’s needs in this area. Healthcare records had been reviewed and were now electronic, which meant information was more easily shared with relevant health professionals.

The service mostly worked in line with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people

Inspection areas



Updated 26 May 2018

The service was safe.

There were enough staff to make sure people were safe.

Medicines were mostly well managed and the registered manager assured us they would immediately address the few stocktaking errors we identified.

The provider assessed and managed risks well.

Staff understood their responsibilities to keep people safe from abuse and were confident about reporting any concerns.

There were good procedures in place to reduce the risk and spread of infection.


Requires improvement

Updated 26 May 2018

The service was not always effective.

People were not unlawfully deprived of their liberty. Some further work was needed to ensure the service always worked in line with the Mental Capacity Act 2005 to protect people�s rights. People�s consent to sharing a room, and all the implications of this, needed further review.

The design and layout of the building was suitable for the client group but shared rooms did not afford sufficient privacy.

A new training programme was in place and staff received the training they needed to carry out their roles.

People�s needs related to eating and drinking, and to their health were well managed. The service worked in partnership with other healthcare professionals.



Updated 26 May 2018

The service was caring.

Staff were patient and treated people with kindness and respect.

People were involved in decisions about their care and were very positive about the care they received.

Staff worked in a way which maintained people�s dignity.



Updated 26 May 2018

The service was responsive.

Care plans had been reviewed and replaced with a more detailed electronic format which reflected people�s individual needs.

There was a range of activities for people and a real commitment to inclusive opportunities for everyone to follow their own hobbies and interests.

There was a complaints procedure in place and complaints were managed well.

People�s end of life wishes were recorded and the service provided sensitive care to people approaching the end of their life.



Updated 26 May 2018

The service was well-led.

The service was well led by a management team who were open, inclusive and empowering.

People were consulted and involved in the running of the service.

There were robust systems in place to monitor the quality and safety of the service and drive further improvement.